Medication reconciliation brings the ER back to 1960

What a blessing and a curse it must have been to practice medicine fifty years ago.

Most internists had only about twenty or so medications that they used regularly. It was a curse not to have effective medications to treat many common ailments but somewhat of a blessing not to have the modern medical nightmare of having patients on 15-20 chronic medications with all the logistical problems of keeping track of them all and watching for any interactions and complications. The use of electronic medical records is helping more and more medical practices keep track of their patient’s medications.

Unfortunately,  far too many emergency room departments believe that it is still 1960 when it comes to patient medications. And it used to be worse.

The accurate and consistent documentation of medications for patients admitted to the ER and the hospital was unregulated and of low priority until early the last decade when the Joint Commission for Hospital Accreditation starting requiring all member hospitals to keep track of their patient’s home medications and to reconcile these lists while in the hospital and on discharge. As of 2007, only 66% of hospitals actually documented a patient’s home medications though this seems to have improved. But from personal experience, the effort is often substandard.

The documentation forms for medication reconciliation are often confusing and poorly designed. Sometimes there are 2 or more lists which often contradict each other. Medications are frequently misspelled and dosages given in the wrong units or route. Yet, the single worst aspect is that these reconciliation lists are often jaw droppingly inaccurate to the point of being mostly fictional and this is despite the fact that this information is acquired by licensed medical professionals (mostly nurses and physicians).

The inaccuracy of this documentation appears to be a combination of two factors. 1. The medical staff appear to put forth much more of an effort to acquire a list (any list) than in maximizing the accuracy of such a list and 2. Many patients and their families have a very difficult time keeping track of their own medications.

The second problem is a universal headache for most health care workers. Patients either forget their medications or bring outdated lists or only some of their medications and family members are too infrequently involved in the patient’s medical care to help give information or the one member who knows the most is never available. These are considerable problems but short of a national electronic database to keep an accurate record of each patient’s medication list in real time (more on this in a future post) there is not much that can be done on the patient side. Yet, many patterns and common pitfalls can be seen and dealt with to significantly improve the accuracy of this information.

For example, patients often put all of their medications in one container to bring with them to the ER. However, this fact alone does not constitute an accurate list. Patients will put both medications that they have discontinued in addition to their current medications into the same bag. Or they will put their medications into the same container with their spouse’s medications. I frequently see this type of error.  It’s as if the person recording these medications didn’t bother to read the name on the labels but simply assumed that every single medication in a specific container was currently being taken by the patient. In one case, a female patient’s medications were recorded to include doxazosin which is a medication taken to shrink the prostate in males. The doxazosin was the patient’s husband’s medication and the pill bottle label even stated “take nightly for prostate” and this line was included in the medication reconciliation list.

Patients frequently forget to include medications. They often do not mention medications that are not taken in pill form such as inhalers, injected insulin, home oxygen, topical patches, and eye drops. They frequently forget to mention non-prescription medications such as aspirin and the chronic use of such over the counter medications as non-steroidal anti-inflammatories  which can have profound clinical consequences.  Often, specific medications need to be asked about for patients with certain conditions, however, in my experience, if the the medication is not in the bag then it doesn’t go on the list.

This nit picking about the accuracy of medication lists is far more than cosmetic. There is a lot of data out there that medication side effects and complications result in a significant number of ER visits each year. A 2008 Canadian study found that 1 in 9 ER visits were related to medication problems; either adverse reactions, noncompliance, or wrong medication or wrong dosages. Obviously, the inability to get an accurate list of home medications can significantly impair the staff’s ability to recognize and treat for medication problems. Additionally, an accurate medication reconciliation list is important for discharge planning to ensure that patient don’t go home and start taking medications that they shouldn’t and that nobody asked them about.

The cynical reader would think that this lackluster effort to reconcile medication lists is mostly limited to big city public hospitals with mostly indigent patients but it’s actually a quite frequent occurrence in high dollar private hospitals belonging to huge national corporations. The priority in private hospitals is to move patients so as to facilitate higher volume and increased billing. The priority is not accuracy.   It’s obvious that the ER staff is simply documenting to satisfy the regulations in the same way that public school teachers frequently “teach to the test”.  In one incidence, the medication list appeared to be simply copied verbatim from the records for the patient’s previous ER visit about 3 months prior. This despite the fact that the patient was perfectly awake and alert and told me that her doctor had since discontinued those prior medications and started her on all different ones.

Patients need to be aware of this if and when they have to go to the emergency room. The best strategy is to double check the ER staff’s work. Try and make sure that you have all of the current medication bottles or an up-to-date and accurate list. Ask to see the medication reconciliation form after the staff have filled it out to verify to yourself or your family member that what is listed is accurate to the best of your knowledge. If you don’t know or are unable to get a full and accurate medication list then make sure that the staff are aware of this and that they document somewhere on the medication reconciliation that the list is not yet complete.

Chris Rangel is an internal medicine physician who blogs at RangelMD.com.

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  • doc99

    Trust no one, Dr. Mulder.

  • http://www.skincancercenter.com Brooks

    I have the same thought… What would it be like to practice years ago, and I think you hit it on the head… There would be some pros and some cons… I could do without the crazy insurance aspect.

  • Muddy Waters

    Thanks for reminding me why I’m glad I specialized.

  • rbcd

    The biggest culpability in the are the patients and pharmacists! Why shouldn’t a patient know what medications he/she is taking (at least keep anaccurate list) and why should pharmacies who are all alligned in allscripts, etc report on medications axtually preacribed? Physicians are required to keep lists but what about pharmacies providing lists to a national drug center? Then physicians and hospitals could obtain accurate info without confusing patients too

  • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

    Hmm… As far as I know Surescripts (and previously RxHub) has a service just for ERs to obtain a current medication list on demand. I ran into it first over 6 years ago, so by now it should be as good as what is made available to ambulatory prescribers. Everything the PBMs have on record, should be on that list. Over the counter stuff won’t be there and meds paid for in cash (4 dollars Walmart specials) may not be there either.

  • Marc Gorayeb, MD

    Despite discussing the issue thoroughly, the author misses the point almost entirely. No electronic database, however sophisticated, can solve the problem of patients not knowing their own current medications, and not keeping their own current list. If a patient can’t do this very basic task, then the physician should question whether it is appropriate or safe for the patient to be taking the medication in the first place.

    • Kristin

      I have to disagree. Patients often aren’t educated at any meaningful level about their bodies–when I took Medical Terminology as an elective in high school, the vast majority of what I learned came as a total surprise. I’m talking about things that seem basic in retrospect–that gravity isn’t what keeps food in our stomachs, that there are different kinds of blood cells, what and where our organs are and what they do. “Health class,” the only required medical education we got, covered two things: Gatorade and STDs.

      I come from a small, rural town, and if the education I received is any indication, it’s not surprising that patients from my kind of background forget what their medications are for. They don’t have the background to meaningfully understand what an NSAID is–all they know is that it helps the pain and keeps the swelling down. They don’t look an an NSAID and think, “Kidney tubules.” They think, “Did I take one of those already? I really want to take another one for my sore knee.” The concerns are concrete and immediate, and anything less so gets subsumed by the immediate needs. It’s similar to, or maybe even an example of, the “Smaller sooner, larger later” reward structure in Skinnerian behaviorism.

      It’s even harder with medications they don’t understand the need for. Medications like statins, where they’re relying on the explanation of a doctor who can spend maybe 10 minutes with them and could easily have poor communication skills to begin with, don’t seem to do any immediate good. There’s a whole family of statins; how do they remember which one they’re on? How often do they think about it? How important is it to the quality of their daily life, right now, that they devote space in their brain to remembering not only which specific statin they’re on, but how much and when? If they lay out their pills or have a routine, it’s even easier to get in the habit of just taking the pill without looking at the bottle.

      Doctors approach medications from the perspective of knowledge. You know what you’ve prescribed and why. Patients often don’t know either of those things, and the sound-byte explanations they get in their brief office visits don’t do the trick. But people are often reluctant to tell their doctors that they don’t understand; social pressures combine to make them feel more comfortable nodding, smiling, and then not taking or inappropriately taking their medications.

      Electronic records won’t solve the problem of patient non-comprehension. Only a meaningful update in K-12 eduational curricula will do that, and I don’t see it happening anytime soon. In the meantime, who’s telling patients why it’s important for them to bring the lists? I don’t mean a receptionist telling them to do it, or even giving them a five-second spiel about it. I mean that someone needs to sit down with the patient and explain the structure of medical records and the problems that could come about if the treating physician doesn’t know what they take. Who’s educating patients about the existence of multiple, conflicting, sometimes non-electronic records?

      When doctors seem so knowledgeable, it’s easy to assume that they know what medications we’re on. Before I became interested in medicine, I was under the impression that my medical records could follow me. I wasn’t a particularly under-educated patient compared to the general population, but I was ignorant, in all the ways that annoy doctors, about how medical record-keeping works in the US.

      There is no coherent medical education that we go through before we become patients. We simply grow up in the medical system, often with the same pediatrician for years before we suddenly find ourselves off our parents’ insurance, hunting for our own doctor, not sure whether we’re seeing an NP or PA or what those differences mean, trying to figure out where our records are and what they say. (And that’s if we’re middle-class, our parents had insurance, and we get the chance to stay in school and then get a job. People with lower socioeconomic status may never have any kind of PCP–their medical care is urgent clinics and the ER.) If we’re lucky enough to have insurance and get a new primary care physician, how much time do we spend with them? How much of an incentive is there for them to sit down with us and explain how medical record-keeping works and what we can do to faciliatate our own care? Given the current structure of PCP reimbursement, I’m going to say that the incentive is pretty small. The incentive is to get us in and out in a timely fashion. PCPs are decrying the death of time to talk and think, but the ramifications are bigger than just not getting an accurate handle on the patient’s symptoms and state of mind. Patients are not educated about their bodies, and without understanding their bodies, it’s extremely unlikely that they’ll fully understand their medications and the importance of their medications.

      Any approach to the problem of medication lists needs to be pragmatic. We need to change the system in some way–not in a way that requires patients to keep doing something they already don’t do. The easiest way is to integrate EHRs. The next easiest way is to educate patients. I don’t see medicine doing either of those things well anytime soon.

      • Fam Med Doc

        “How much of an incentive is there for them to sit down with us and explain how medical record-keeping works and what we can do to faciliatate our own care? Given the current structure of PCP reimbursement, I’m going to say that the incentive is pretty small. The incentive is to get us in and out in a timely fashion. ”
        “We need to change the system in some way”…” I don’t see medicine doing either of those things well anytime soon”.

        Dear Kristen,
        Good points in your response. From the above selections I cut & pasted, the REALITY is as a primary care doctor, you & the rest of society don’t pay me enough to be able to spend time enough to educate you in the way you need & want. And btw, I simply LOVE to spend time teaching & educating my patients. It’s a joy. For real. But it’s also a financial IMPOSSIBILITY. If I see any LESS patients, I won’t pay my office rent, or my staff, or the electricity- all real important obligations. I gotta see a certain amt of patients/day. I gotta. But when society decides to pay it’s primary care docs what we are worth- by increasing the per visit pay by your insurance company- then we will be able to spend time you & educate. And buying an EMR? LOL! I don’t have a DIME for such a lavish expense. I’m just praying I have the money in my account to pay my employees payroll tax next month in July. Maybe you can throw up a prayer, too.

        I know the problem isn’t your all fault-it’s all of ours in society- I’m just explaining how this can be solved, which as you insightly wrote, won’t be any time soon.

  • PDM, MD

    As an emergency physician, I found this article insightful and consistent with my experience. One issue that was not addressed, however, is the administrative load placed on the nurses by this requirement. While reconciliation is important, it is one more of many federally mandated requirements that takes the nurses away from their patients and places them servicing the computer instead. Time is the most precious commoditity in an emergency department and rarely is it in excess.

    Until a easy, technology based solution is found, the lists will likely remain inconsistent and inaccurate.

  • http://www.justsayah.org Helene Eisman Fisher

    I am glad you covered this issue. Say Ah! always advocates that patients and caregivers make, maintain and keep a list of medications – prescription and over-the-counter, herbs, supplements and vitamins. It is important that every person keep track of his/her medications or that his/her caregiver do so. In fact, we believe in this so strongly that we created a wallet-size, portable and discreet card that reminds people to make this list (and keep it with them), and to have one at home, pinned to the fridge or near the front door. The online version is available here: http://www.justsayah.org/tips-for-you/tips-for-talking-with-your-doctor in English, Spanish, Haitian Creole and Russian.