Exploit human factors principles to facilitate this difficult but important task.
Medication reconciliation is the comparison and combining of two or more medication lists. It usually involves a conversation between the patient and a health care professional, and can occur in many different situations. In this chapter, we will explore medication reconciliation scenarios and EHR designs that might be facilitated in inpatient and ambulatory settings. The first section focuses on one example of medication reconciliation in aninpatient setting. It describes a functional prototype called “Twinlist” and illustrates how Twinlist could be used when a patient is being discharged from the hospital. The second section focuses on medication reconciliation in theambulatory setting, and focuses on the patient's role in annotating and correcting their EHR medication list at the very beginning of visits.
Consider this inpatient clinical scenario:
Mr. Jones is a 74-year-old, married businessman, now retired. He’s being treated for coronary artery disease (he received a stent at age 70), constipation, diabetes, hyperlipidemia, GERD, hypertension, and mild dementia. His primary care physician, Dr. Barnes, sent Mr. Jones to the hospital Monday morning after his wife insisted he go to the clinic because he was having trouble breathing and was rubbing his chest. He had been doing fine until sometime the previous night. His wife said he had seemed quite well Sunday afternoon, when two of their sons came over to watch the game with him. They made it “a little tailgate party, hot dogs with sauerkraut and everything."
Examining Mr. Jones, the hospital physician found moderate pulmonary congestion, but no EKG changes. He tested negative for Troponin. Because of his past medical history and the strong history of Myocardial infarction (MI) in his family, he was admitted and treated. By Wednesday afternoon, Mr. Jones is ready to leave and can be discharged from the hospital. One of the medical house officers is discharging Mr. Jones and as part of this process, reconciling his medications.
In this scenario, the physician discharging the patient has to actively compare two lists:
Our physician will then decide which medications could be continued after the patient is discharged and which should be stopped.
Let’s watch a short video about a prototype called “Twinlist,” an award-winning demonstration of a proposed medication interface.
If you’d like to explore Twinlist in more detail, try the interactive prototype:
Here are some of Twinlist’s features that make it an effective interface:
Let's look through some individual images of Twinlist (Figure 3.1 to3.5) to review the details. This illustrates medication reconciliation during hospital discharge.
Physicians use two medication lists to reconcile medications in an ambulatory setting:
Healthcare team members can collect information about patients’ adherence to their medication regimens either by interviewing the patients or by giving the patients a form to fill out. The latter option may save the office staff time. The diagram below shows a simplified workflow for medication reconciliation in the outpatient setting.
The medication reconciliation workflow may vary from clinic to clinic, depending on what roles said clinic assigns various members of its staff. In some clinics, nurses interview patients and update the medication list, adding annotations about patients’ adherence where necessary. Physicians subsequently confirm these annotations with the patients and seek clarification about any uncertain details. Other clinics give patients printouts of their current medication list as recorded in the EHR, which the patients can then annotate. In other clinics, physicians review medication lists with the patients in the course of their visits.
Some specialists, particularly those in surgical subfields, may review medication lists less precisely, focusing only on the medications they have prescribed, such as post-operative antibiotics or pain medications. These specialists need to be able to reconcile the medications they’re responsible for without assuming responsibility for the entire medication list. Reconciliation interfaces might offer a means of conveying that specialists have reconciled the medications they’re responsible for, and only those medications. It might be accomplished by giving users the option of clicking on ‘Acknowledged’ or ‘Reviewed but not approved’ in addition to the fuller ‘Reconcile & Sign.’
During the visits, patients and physicians agree upon new plans of action. Physicians might then prescribe and makes other changes in the medication list. Patients then get updated copies of their list to take home.
After the patient has reviewed the medication list, the physician must review the patient’s annotated list. They’ll have a conversation about any discrepancies and uncertainties in an effort to resolve them. Then those curated details would be added to the patient's record.
The list in Figure 3.16 is the physician’s final review of medication list. Once the physician approves the list by pressing the “Confirm Review” button in the upper right, the EHR updates the medication list in the patient’s record and saves all comments about adherence. The category in which a medication has been placed in the list specifies how the final reconciled medication list is saved in the patient’s record.
Category | Consequence |
---|---|
Not sure | Keep the medication in the reconciled list, but mark as “not sure.” |
Not taking | Remove the medication from the reconciled medication list. |
Taking | Keep the medication in the reconciled list. |
Taking (but annotated as “not taking” or “not taking as prescribed” by the patient) | Keep the medication, but preserve the adherence comments from the patient in the record. |
In this design physicians would need to learn the drag and drop functionality (or alternate menu functions andaffordances) (See Our Eyes Have Expectations in the Human Factors chapter) that allow moving medications from one category to another.
After the medication reconciliation at the start of the visit, the physician takes further information about the patient's medical history, does an examination, makes clinical decisions, and collaborates with the patient to make a plan of action. Their plan might include changing or adding to the patient's medications.
Patients often report uncertainty about their medication list. For instance, patients may not be able to recognize...Read more
Patients often report uncertainty about their medication list. For instance, patients may not be able to recognize or pronounce the names of medications they've been taking for some time. Some people may refer to medications by intended purposes: "a blood pressure medicine.” Conversations outside the formal office visit (via phone or email) may have conveyed information that didn’t make it to the patient’s record.
Medication reconciliation implies certainty: after it's recorded, the data acquires the status of fact. That certainty is not always justified. We need methods to represent uncertainty in these human aspects of technology. An EHR might represent uncertainty by including text comments or with quantitative measures such as confidence ratings or likelihood algorithms.