Monday, November 22, 2010

Smart Medication Reconciliation and Problem Lists

Last week, I spent a few days in California when both my parents ended up in the hospital with different issues.   They're home, settled and doing well at this point.

Just as when I first wrote about experiencing healthcare with my family, there are important lessons to learn about this trip.

As we strive to achieve meaningful use and create health information exchange in the US, the need for smart medication is critical.

Our current national systems do a good job of retrieving a history of medications that were filled or reimbursed, but they do not do a good job of identifying those medications which are active - that is left to the patient or their family.   What do you do if the patient is unable to answer, the family is unavailable, or the patient/family does not really know what medications are current.

My family was able to provide history such as "the green capsules, or the pink pill", which were insufficient to achieve accurate medication lists.

Similarly, it can be challenging to retrieve an active problem list from claims data, which is often inaccurate or imprecise.

The result is that my parents received unnecessary medications as well as did not receive necessary ones.

The hospital focused on the acute inpatient problems without attending to the more chronic outpatient ones.

How do we solve this?

1.  Ensure every patient has a personal health record, an electronic medical home with an updated medication list and problem list.

2.  Implement novel decision support that infers active medications by examining recent refill history and active problems by examining available data sources such as lab history, recent diagnostic studies which imply active diagnoses i.e. a recent high hemoglobin A1c in a patient on insulin implies diabetes.  Here's a design from AnvitaHealth, a decision support services provider for which I serve as a Board member.

3.  At its very simplest, carry a wallet card with an active medication list and problem list.

While in California, I isolated every medication in the house, current and historical.   I documented active medications, active problems and the relationship between the medications and the problems.   I reviewed the resulting lists will all family members (with their consent).   My parents will ensure all their clinicians update their records to reflect this accurate information.   They will carry with them to any future hospitalizations.    I disposed of historical medications (safely) to prevent any future confusion.   I isolated medications for each person so there would be no accidental taking of medications intended for other people.

Admittedly as a clinician, I have the training that enables me to do this.

For families without clinicians, create a shopping bag of medications and take it to a primary care visit for a family medication reconciliation exercise or ask for the help of health coach.

As we build electronic systems, the outpatient to inpatient transition will  become more seamless and accurate, but during this time of evolving connectivity and less than perfect use of electronic health records, I encourage everyone to reconcile their medications and problems, get them into a PHR, and share them widely with family members and caregivers.

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