MedManage The development of a tool to assist medication reconciliation in a rural primary care clinic
The development of a tool to assist medication reconciliation in a rural primary care clinic
Traci Jarrett, PhD, MPH (Research Assistant Professor), Jill Cochran, PhD, APRN, C-FNP (Associate Professor, Clinical Sciences), Adam Baus, PhD, MPH, MA (Research Assistant Professor) , & Kayla Delmar, OMS II (Student)
Journal of the American Association of Nurse Practitioners
Background and purpose: Medication reconciliation is a critical step in the health care process to prevent hospital readmission, adverse drug events, and fall prevention. The purpose of the study was to pilot test a medication reconciliation process, MedManage, informed by the Medications at Transitions and Clinical Handoffs (MATCH) toolkit with nursing staff in a rural primary care clinic.
Methods:The research team conducted 38 chart audits of high-risk patients, and preintervention and postintervention were conducted to assess changes in medications reported by patients. The intervention included a chart audit tool and medication reconciliation tool created by the interdisciplinary team, MedManage, were pilot tested in the clinic.
Conclusions: The Use of MedManage resulted in improvements in patient reporting of over-the-counter (82% of patients reported previously unrecorded OTCs), PRN medications (3% unreported), and herbal supplements/vitamins (28% reported previously unrecorded vitamins).
Implications for practice: MedManage may be an effective tool to assist clinical nursing staff to attain a more complete and accurate medication list from patients and should be assessed more broadly across rural primary care clinics.
As part of an ongoing clinical research collaboration series, a rural primary care clinic and the local hospital in the same community identified hospital readmissions as a priority focus area for quality improvement and research. To assess provider perceptions of underlying issues and barriers for their patient population, an informal brainstorming session around factors that contribute to frequent hospital readmission identified polypharmacy and challenges with medication reconciliation across health care entities as a priority area for quality improvement. To address these challenges, the clinic adapted a process designed to reduce medication errors supported by the Agency for Healthcare Research and Quality, the Medications at Transition and Clinical Handoffs (MATCH) toolkit. The process was designed to examine the internal processes, workflow, and staff responsibilities related to medication reconciliation within health care settings. The current study used the MATCH toolkit in a novel setting, a rural primary care setting in partnership with a local rural hospital, to design and implement an innovative medication reconciliation process.
Nursing has been at the forefront of medication administration and safety (Ballard, 2003). As prescribing practices have expanded for advanced practice registered nurses, safe and cost-effective care is central to our profession (American Association of Nurse Practitioners, 2015). Each year, medication errors account for 7,000 deaths (Stefl, 2001) and adverse events cost $4,800–$10,375 per patient (Bates et al., 1997; Jha, Kuperman, Rittenberg, Teich, & Bates, 2001).
Persons with multiple chronic conditions and polypharmacy are at highest risk of adverse health events because of inaccurate medication reconciliation, with low-income and older American patients at greatest risk (Gleason et al., 2010; Rodr´ıguez Vargas, Delgado Silveira, Iglesias Peinado, & Bermejo Vicedo, 2016). One in five older adults is taking potentially inappropriate medications (Gleason et al., 2004; Jha et al., 2001; Stefl, 2001). Studies estimate that up to 30% of medication errors are preventable in outpatient settings and up to 50% of hospitalizations for adverse drug events (ADEs; Pretorius, Gataric, Swedlund, & Miller, 2013). Transitions across health care entities, such as hospitals to primary care, are particularly risky for ADE (Gleason, Brake, Agramonte, & Perfetti, 2012; Gleason et al., 2004; Gleason et al., 2010; Rozich & Resar, 2001), are attributed to the most common postdischarge complications, and significantly contribute to readmissions due to medication errors (Agency for Healthcare Research and Quality, 2014)
Medication reconciliation lists are often inaccurate. Studies indicate that medication discrepancies result from lapsed medications, challenges in communication across health care facilities (specialists, hospitals, primary care clinics, emergency care, pharmacies, and non-PCP urgent care) (Chandra & Gerwig, 2007), and challenges with nonintegrated electronic health records (Bell et al., 2011; Cornish et al., 2005; Gleason et al., 2004; Haynes, McKibbon, & Kanani, 1996; Hubbard & Daimyo, 2010; Sabbatini, Kocher, Basu, & Hsia, 2016). Additional challenges in medication reconciliation result from patient nonadherence or inability to recall medications (dosage and frequency); low health literacy; patient nondisclosure, either intentional or inadvertent (being unaware that over-the-counter and herbal medications should also be reported); and the use of previous prescriptions to self-medicate (Backes & Kuo, 2012; Bell et al., 2011; Cornish et al., 2005; Gleason et al., 2004; Haynes et al., 1996; Hubbard & Daimyo, 2010; Koronkowski, Semla, Schmader, & Hanlon, 2017; Locquet et al., 2017; Sabbatini et al., 2016). Studies estimate that between 30% and 70% of patient records reviewed had medication errors (Gleason et al., 2012), with an average of 3.2 discrepancies per patient (Andrus & Anderson, 2015). In one study, 85% of medication errors originated in the medication history (Gleason et al., 2010). During transition following hospital discharge, a study found that of 94 patients, 94% had incomplete information on at least one medication (Lee, Nishimura, Ngu, Tieu, & Auerbach, 2014). Over-thecounter medications and herbal supplements are among the most commonly omitted medications in the medication reconciliation process. It was determined that up to 15% of older adults are at risk of potential drug interactions by a study that examined the use of over-thecounter medications and dietary supplements from 2005 to 2011 (Qato et al., 2016).
Despite known contraindications among some herbal supplements, as a whole, there are challenges with quality control and safety monitoring (Woo, 2007). Evidence-based guidelines for providers caring for patients using supplements are lacking, and adverse events suspected to be related to an over-the-counter medication are difficult to report and evaluate (Woo, 2007). Patients are often unaware of possible drug interactions and do not report them to their provider during the medication reconciliation process (de Souza Silva et al., 2014). A systematic review of herbal medications in elderly patients found that users were exposed to at least one potential drug interaction with herbal supplements and that one third of current users were at risk of drug interactions (de Souza Silva et al., 2014).
If appropriate processes are in place, medication reconciliation can take 15–30 minutes to complete and have an estimated hospital savings (based on 43,312 inpatient admissions) of $11.4 million annually (Ballard, 2003). Medication reconciliation interventions demonstrating modest improvements included asking patients to keep medication diaries or bringing their medications to appointments and asking pharmacy staff to do the medication history at primary care centers. One study that included standardizing the medication reconciliation process improved the accuracy of the medication list from 9.7% to 70.7%; however, documentation of over-the-counter medications was incomplete (Nassaralla, Naessens, Chaudhry, Hansen, & Scheitel, 2007).
As a part of the MATCH process quality improvement study, nurses, clinicians, reception staff, information technology, administration, and researchers worked together as a defined leadership team to assess the clinic’s internal processes related to medication reconciliation, to identify gaps and strengths, and to address them. To that end, our lead clinical researcher worked with nurses to develop a consistent definition of medication reconciliation accuracy and a clinic intervention tool, MedManage, to use with patients to assess medications based on symptoms. The tool was pilot tested using prechart and postchart audits to investigate the number of medication discrepancies, including all medications, OTC, PRN, and herbal supplements. The aim of the study was to assess whether MedManage aided nurses and providers to work with patients to develop a more comprehensive active medication list and reduce discrepancies that could lead to medication errors.
MedManage was implemented in the primary care setting as part of the MATCH toolkit. The clinic serves a county with a population of approximately 35,000 plus surrounding counties, with 69.7% living in mostly rural areas (United States Census Bureau, 2010). The Appalachian Regional Commission socioeconomic report indicates that the county has an 18.4% poverty rate and the per capita income was $34,932 in 2016 (Appalachian Regional Commission (ARC), 2011). The clinic has a rural health designation from the Centers for Medicare and Medicaid Services and had 59,354 patient encounters from July 2017 to June 2018. This study was part of a larger study designed to leverage the MATCH toolkit in a rural primary care setting with cooperation from the local hospital to reduce errors during the medication reconciliation process following discharge and transition to primary care follow-up. Medication Reconciliation at Transitions and Clinical Handoffs is an eight-step process that includes 1) convening an interdisciplinary team, 2) mapping the current medication reconciliation process, 3) identifying potential areas of improvement, 4) establishing a measurement strategy, 5) designing changes to the medication reconciliation process, 6) piloting the change in the facility, 7) providing education and training, and 8) assessing/evaluating the changes. Unfortunately, the rural hospital was only able to complete steps 1–2 because of staffing turnover, but their brief participation led to identification of key, yet easily addressed, challenges with the communication between facilities. This study reports results from a pilot study of a new process of medication reconciliation that were developed with the leadership team using steps 1–6 of the MATCH process in the rural primary care clinic only. This includes assessing the accuracy of the medication reconciliation process, new medications not previously reported, changes in existing medications, and over-the-counter and prescription medications taken as needed. All methods were approved by the West Virginia School of Osteopathic Medicine Institutional Review Board (protocol 2016-3).
Intervention: MedManage and audit tool development
In step 1, the rural primary care clinic interdisciplinary team met 6 times to address the steps in the MATCH process. Researchers also used deidentified primary care clinic electronic health record data and hospital discharge data to identify characteristics of patients at greatest risk of admission and readmission (within 30 days after discharge) to the rural hospital. These characteristics were used to identify highest-risk patients to pilot a revised medication reconciliation process, including those who were aged 65 years or older, whose primary insurance was Medicare/Medicaid, who had three or more disease diagnoses, and who had polypharmacy. As part of steps 2 and 3 of the MATCH process, researchers also conducted interviews with patients, caregivers, the partner hospital staff, and the clinic staff to provide multiple perspectives of the transition from hospital to follow up with primary care providers. In addition, other primary care centers shared information about their medication reconciliation process. Step 4 included the interdisciplinary team that identified a shared definition of accurate medication reconciliation and created a chart audit tool (Figure 1) that included medications that were not usually listed during the medication reconciliation process. These included herbal supplements, vitamins, OTC creams, lotions and ointments, and prescription medications that patients take PRN. The research team also created MedManage (step 5), a diagram designed to stimulate patient recall of medications based on simple visualized mapping of medication use to area of the body Figure 2.
The pilot testing of the new medication reconciliation process within the rural clinic for step 6 of the MATCH process included conducting pretests and posttests to assess whether patient records were congruent with the definition of accurate medication reconciliation created by the interdisciplinary team. First, a pharmacy technician and a research assistant reviewed 10 preliminary charts to determine whether the current audit tool captured all medication classifications and details outlined by the team. An accurate medication list was characterized by the interdisciplinary team with the following five essential traits:
Every prescription medication currently prescribed by ALL the patients’ providers. The correct dose, route, time, and how the patient is actually taking it.
Every prescription medication that the patient uses PRN from every provider and how often they used it within the last 2 weeks.
Every over-the-counter and herbal medication that they use on a regular basis, including oils, patches, lotions, and supplements from local nutrition stores.
Every over-the-counter medication or product, including shakes, taken on occasion, especially within the last 2 weeks.
Any allergy or adverse reactions they experienced to any medication or product.
Following audit tool revisions, the tools were more broadly tested with a single adult care provider at the clinic over a 3-week period. Reception staff identified patients meeting the high-risk criteria and included MedManage in the paperwork to be completed by the patient. The pharmacy technician and research assistant worked with patients in the waiting room to complete MedManage.
The research team used the audit tool to assess patient medication lists before and after implementation compared with their recorded medication list. Any medications that had not previously been indicated were counted and categorized by the type of medication. A total of 38 patients were evaluated.
Ethical considerations—Assessing changes
At each step of the MATCH process, the research team worked with clinic staff to ensure ethical consideration of patients. In addition, preliminary interviews were conducted with patients and their care givers to assess their medication reconciliation processes in the home. Results from the pilot were shared with the interdisciplinary team, administrators, and other clinic providers at a final team meeting. Clinic-wide implementation challenges were identified and potential solutions addressed. The inclusion of clinic staff for the duration of the study ensured continuous feedback on workflow, privacy, and implementation.
Using the high-risk criteria defined above, 38 chart audits were conducted. Results indicate that 40% of the patient charts audited had incomplete or inaccurate medication lists. Of the 38 patients for whom the research team used the audit tool and MedManage for pretests and posttests:
Patients took an average of six medications (range 1–21 medications per patient)
Eighteen percent of the patients surveyed had no change in any medications
Eighty-five of the patients had a change in active medications
Three percent of the patients had a change in prescribed PRN medication
Eighty-two percent had an over-the-counter medication that they took as needed that was not previously recorded
Twenty-eight percent of the patients listed a vitamin not previously recorded
Fourteen percent of the patients listed a new lotion that was not previously recorded
Clinic implementation challenges
The primary challenge to the original purpose of the study was the unanticipated organizational barriers from the partner clinic hospital. Although they fully supported the study, key staff turnover made continued participation impossible. The final interdisciplinary team meeting also included administrators and other clinic staff to help identify barriers to clinic-wide implementation of MedManage. Representatives from front office staff indicated that the pilot process went smoothly. Although the participants widely accepted the importance of accurate medication reconciliation and agreed that MedManage was an important tool to capture previously overlooked medications, they also identified potential challenges to broad implementation. These contextual challenges included the following:
Clinic staff, such as the pharmacy technician or research assistant, often needed to aide patients in the waiting room to complete MedManage. This requires either additional staff or shifting current staff responsibilities to include this assistance.
The electronic health record frequently does not include over-the-counter medications and herbal supplements or ways to accurately identify medications as PRN.
The way in which over-the-counter or PRN medications appear in the electronic health record for individual patients may “push down” needed prescription medications on the chart, making them difficult for providers to quickly identify.
Some of the patients found the instructions for MedManage hard to follow.
Patients were reluctant to disclose all medications and did not want to complete the tool.
This study included an intervention, MedManage, to assess the accuracy of medication reconciliation in a rural primary care clinic. MedManage was developed as a supplement of the MATCH toolkit and applied in a rural primary care setting. It specifically focused on unreported and under-reported over-the-counter and PRN medications and herbal supplements that could have potential negative drug interactions. The tool was successful in gaining additional medications that had previously not been reported. The rate of OTC medications increased by using MedManage (82%) suggests that the patients do not recognize the importance of informing their health care provider about OTC medications. Interaction of OTC medications and prescription drugs is a hidden threat to outcomes of safe and effective patient care. The MedManage tool, then, has a very real, pragmatic benefit to nurse practitioners in primary care and patients served in that it gives attention to the long-standing problem of medication reconciliation and offers practical tools to address it. The primary limitation is the small sample size; however, the MATCH process provided valuable information about clinic work flow, transition of care across medical entities, patient and caregiver perspectives, and challenges for nurses and providers associated with medication reconciliation in a rural primary care setting.
This study supported previous research that over-thecounter drugs and herbal supplements are underreported by patients during medication reconciliation. The use of this tool to identify and monitor typically under-reported medications may mitigate potential risks of medication interactions. Knowing additional medications taken by the patient may assist nurses and providers in safer prescribing and improve fall risk assessment. Globally, interoperable electronic health records capable of being viewed by providers across settings could help prevent medication errors during the medication reconciliation process. However, the availability of such health information technology in the United States is possibly years away, making patient and provider interventions the most likely to succeed. Interventions and patient education can prevent polypharmacy and adverse medication interactions. This study illustrates potential gaps and solutions within the rural primary care clinic setting for prescribing nurse practitioners.
Additional evaluation is needed to simplify the MedManage tool for low health literacy patients, and needs to be tested more broadly across clinics to ensure generalizability to the high-risk, older adult, rural patient population. Education about these types of medication omissions needs to be identified and addressed among medical professionals including nurse practitioners, physicians, pharmacists, nurses, and nutritionists. Further research is needed to improve our understanding of the impact of using MedManage as a tool for medication reconciliation at clinical handoffs. Continued attempts to engage critical access hospitals should be addressed and communication emphasized, as a limitation of our study was the early dropout of the partner hospital due to factors beyond the control of the study. Although electronic health records and more automated medication reconciliation tools hold promise for future benefit to patient care and safety, this research effort highlights a practical decision support tool capable of preventing lifethreatening medical errors and one that could be used to improve fall risk assessment. The importance of achieving accurate and complete medication reconciliation for improved safety and outcomes is an ongoing priority for nurse practitioners in rural patient care and one in need of innovative, tailor-made approaches for expedited success.
Research reported in this publication was supported by the National Institute of General Medical Sciences of the National Institutes of Health under Award Number 2U54GM104942-02 and the West Virginia Health Outcomes Policy Evaluation through the Claude Worthington Benedum Foundation. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The authors acknowledge the nurses and staff at Robert C. Byrd Clinic for their support and participation.
Traci Jarrett and Jill Cochran contributed to creating the idea for the project, grant writing, and submission, which funded the project, project implementation and management, data collection and analysis, and manuscript writing. Adam Baus contributed to the idea for the project, data collection and analysis, and manuscript editing. Kayla Delmar contributed to data interpretation and manuscript editing.
Agency for Healthcare Research and Quality. (2014). Adverse events after hospital discharge. Patient Safety Network. Retrieved from https://psnet.ahrq.gov/primers/primer/11
American Association of Nurse Practitioners. (2015). Nurse Practitioner Prescriptive Privilege. Retrieved from https://aanp. org/images/documents/publications/prescriptiveprivilege.pdf.
Andrus, M. R., & Anderson, A. D. (2015). A retrospective review of student pharmacist medication reconciliation activities in an outpatient family medicine center. Pharmacy Practice, 13, 518.
Appalachian Regional Commission (ARC). (2011). Economic Overview if Appalachia-2011. Retrieved from http://www.arc.gov/research/ EconomicReports.asp.
Backes, A. C., & Kuo, G. M. (2012). The association between functional health literacy and patient-reported recall of medications at outpatient pharmacies. Research in Social and Administrative Pharmacy, 8, 349–354.
Ballard, K. A. (2003). Patient safety: A shared responsibility. Online Journal of Issues in Nursing, 8, 105–118.
Bates, D. W., Spell, N., Cullen, D. J., Burdick, E., Laird, N., Petersen, L. A., … Leape, L. L. (1997). The costs of adverse drug events in hospitalized patients: Adverse Drug Events Prevention Study Group. Journal of the American Medical Association, 277, 307–311.
Bell, C. M., Brener, S. S., Gunraj, N., Huo, C., Bierman, A. S., Scales, D. C., & Urbach, D. R. (2011). Association of ICU or hospital admission with unintentional discontinuation of medications for chronic diseases. Journal of the American Medical Association, 306, 840–847.
Chandra, A., & Gerwig, J. (2007). Addressing the challenges associated with polypharmacy and adverse drug events: Identifying preventive strategies. Hospital Topics, 85, 29–34.
Cornish, P. L., Knowles, S. R., Marchesano, R., Tam, V., Shadowitz, S., Juurlink, D. N., & Etchells, E. E. (2005). Unintended medication discrepancies at the time of hospital admission. Archives of Internal Medicine, 165, 424–429.
de Souza Silva, J. E., Santos Souza, C. A., da Silva, T. B., Gomes, I. A., de Carvalho Brito, G., de Souza Araujo, A. A., ´ … da Silva, F. A. (2014). Use of herbal medicines by elderly patients: A systematic review. Archives of Gerontology and Geriatrics, 59, 227–233.
Gleason, K., Brake, H., Agramonte, V., & Perfetti, C. (2012, August). Medications at Transitions and Clinical Handoffs (MATCH) toolkit for medication reconciliation. Retrieved from http://www.ahrq. gov/professionals/quality-patient-safety/patient-safety-resources/ resources/match/index.html.
Gleason, K. M., Groszek, J. M., Sullivan, C., Rooney, D., Barnard, C., & Noskin, G. A. (2004). Reconciliation of discrepancies in medication histories and admission orders of newly hospitalized patients. American Journal of Health Promotion, 61, 1689–1695.
Gleason, K. M., McDaniel, M. R., Feinglass, J., Baker, D. W., Lindquist, L., Liss, D., & Noskin, G. A. (2010). Results of the medications at transitions and clinical Handoffs (MATCH) study: An analysis of medication reconciliation errors and risk factors at hospital admission. Journal of General Internal Medicine, 25, 441–447.
Haynes, R. B., McKibbon, K. A., & Kanani, R. (1996). Systematic review of randomised trials of interventions to assist patients to follow prescriptions for medications. Lancet, 348, 383–386.
Hubbard, T., & Daimyo, S. (2010). Thinking outside the pillbox: Medication adherence and care teams. Retrieved from http://www.nehi.net/ writable/publication_files/file/care_teams_paper_final_electronic.pdf.
Jha, A. K., Kuperman, G. J., Rittenberg, E., Teich, J. M., & Bates, D. W. (2001). Identifying hospital admissions due to adverse drug events using a computer-based monitor. Pharmacoepidemiology and Drug Safety, 10, 113–119.
Koronkowski, M. J., Semla, T. P., Schmader, K. E., & Hanlon, J. T. (2017). Recent literature update on medication risk in older adults, 2015–2016. Journal of the American Geriatrics Society, 65, 1401–1405.
Lee, K. P., Nishimura, K., Ngu, B., Tieu, L., & Auerbach, A. D. (2014). Predictors of completeness of patients’ self-reported personal medication lists and discrepancies with clinic medication lists. Annals of Pharmacotherapy, 48, 168–177.
Locquet, M., Honvo, G., Rabenda, V., Hees, T., Petermans, J., Reginster, J.-Y., & Bruyere, O. (2017). Adverse health events related to self- ` medication practices among elderly: A systematic review. Drugs and Aging, 34, 359–365.
Nassaralla, C. L., Naessens, J. M., Chaudhry, R., Hansen, M. A., & Scheitel, S. M. (2007). Implementation of a medication reconciliation process in an ambulatory internal medicine clinic. Quality and Safety in Health Care, 16, 90–94.
Pretorius, R. W., Gataric, G., Swedlund, S. K., & Miller, J. R. (2013). Reducing the risk of adverse drug events in older adults. American Family Physician, 87, 331–336.
Qato, D. M., Wilder, J., Philip Schumm, L., Gillet, V., Caleb Alexander, G., Schumm, L. P., & Alexander, G. C. (2016). Changes in prescription and over-the-counter medication and dietary supplement use among older adults in the United States, 2005 vs 2011. Journal of the American Medical Association Internal Medicine, 176, 473–482.
Rodr´ıguez Vargas, B., Delgado Silveira, E., Iglesias Peinado, I., & Bermejo Vicedo, T. (2016). Prevalence and risk factors for medication reconciliation errors during hospital admission in elderly patients. International Journal of Clinical Pharmacy, 38, 1164–1171.
Rozich, J. D., & Resar, R. K. (2001). Medication safety: One organization’s approach to the challenge. Journal of Clinical Outcomes Management, 8, 27–34.
Sabbatini, A. K., Kocher, K. E., Basu, A., & Hsia, R. Y. (2016). In-hospital outcomes and costs among patients hospitalized during a return visit to the emergency department. Journal of the American Medical Association, 315, 663–671.
Stefl, M. E. (2001). To err is human: Building a safer health system in 1999. Frontiers of Health Services Management, 18, 1–2.
United States Census Bureau. (2010). Percent urban and rural in 2010 by state. Retrieved from http://www.census.gov/geo/reference/ ua/urban-rural-2010.html.
Woo, J. J. Y. (2007). Adverse event monitoring and multivitaminmultimineral dietary supplements [electronic resource]. The American Journal of Clinical Nutrition, 85, 323s–324s.