Why is Medication Reconciliation Important in EMRs?

Consider the following clinical scenario: You are a family physician in an EMR-based practice. One of your patients (a 65-year-old male with Diabetes, borderline renal failure, and Hypertension) presents with atypical chest pain. An initial assessment does not reveal an obvious cardiac cause for the chest pain; however, you decide to refer the patient to a cardiologist for further investigation. The cardiologist identifies early congestive heart failure and decides to increase the dose of one medication, adds a new medication, and stops another medication entirely. (The reason for a lack of specifics regarding the medications is simply to illustrate a point. This scenario could be applied to any situation in which multiple providers share care for patients and modify or add new medications to a treatment regimen.)

You may be saying to yourself, “So what’s the problem here? This situation happens every single day across multiple conditions and specialties!” Well, that is quite true, but herein lies the issue. It is what happens after the consultation that is important. Generally a specialist consult note is dictated and sent back to the referring physician. If the specialist uses an EMR, this may be generated directly from the consultant physician’s system. However, the challenge for the referring physician is how to reconcile the changes to the patient’s treatment profile within their EMR. Without the ability to easily update the medication list (in this case, adjust the dose of one, stop another, and initiate a new medication), it is not likely to happen in real-time and, in many cases, not until the next visit. Because the process is not automated and requires a manual reconciliation of the current medication list with the updated changes, it is time-consuming and difficult to manage. In addition, this is not a task that can safely be delegated to a staff member. As a result, it falls squarely on the shoulders of the referring physician.

The challenge is how to reconcile existing data with updated medication information that is constantly changing. (The Collins World English Dictionary defines reconcile as “to make (two apparently conflicting things) compatible or consistent with each other”.) The ability for an EMR to enable this process potentially exists, but a number of enabling core foundational elements need to be in place. Medication information is managed in multiple locations (including referring physician’s EMRs, consulting physician’s EMRs, pharmacy information systems, and regional or provincial drug information systems). The need to reconcile medication data may be triggered in a number of different ways. For example, the receipt of a consultation report into an EMR. A much higher level of connectivity than currently exists is needed for what comes next. The receiving EMR should be able to incorporate medication information as discrete data from the consultation report. By allowing the physician to view the old medication list alongside the newly updated medication list with the ability to accept the changes that are appropriate directly into the EMR, a reconciliation process is enabled. Similar processes should exist between EMRs and Drug Information Systems (DIS) with the ability for a prescriber to accept information from the DIS directly into the EMR in order to reconcile data between the two systems.

While this type of advanced functionality may still be some way off, limited by existing functionality and interoperability between systems, it does provide a future vision of where we need to go. Clinicians will immediately see value in the ability to easily maintain an accurate list of current medications in a patient’s file.

Do you agree or disagree with these observations? How valuable would this kind of functionality be? Add your thoughts by clicking on the “Comments” link below.

Comments

[David Bridgeo]

Agreed. a further level of reconciliation will also be needed, the next time the patient is sent to the pharmacy with his/her refills. The pharmacy will often question if you have made an error when the prescription has been changed as a result of the aforementioned consultation. This makes even more work until the new or updated medication has been in "the loop" for at least one full prescribing cycle.

[Ian Pun]

I run into this issue everyday. I can only reconcile the medication list the next time the patient sees me after they're seen the specialist and I have the specialists' note and I always ask the patient if he had medication changed.

Of course, the simplest way of changing information is to have it centralized and synchronized but who would keep the centralized medication list? Who would be responsible to run these servers? Who has access changing it? GP or specialist?

We can't rely on the computer to give us correct information. We must verify manually and the mere torrent of electronic information (labs, xrays, consults, assessments, hospital reports) an EMR provides creates a great burden on the primary care physician. But that's what we should be trained for - recognizing what information is important and what is not. We are not perfect. We can only try our best.

Ian PUN MD

[Alan Brookstone]

Ian, this is such a critical issue. I have written about it many times in the past. However, we cannot get to medication reconciliation without a comprehensive drug information system (such as the Pharmanet in BC) as a foundation. In addition, EMRs need to have sophisticated medication management capability of which reconciliation is a fundamental piece. If you cannot trust the information and are forced to depend on manual processes indefinitely, then what is the point of the technology support? I will be writing more on this topic going forward.