A New Medication Reconciliation Clinical Reminder: Will it succeed?
A New Medication Reconciliation Clinical Reminder: Will it succeed?
The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) recently implemented the standard that health care organizations will document at each patient encounter with a licensed practitioner that the patient’s medication list is reconciled between what the patient reports is being taken and what the medical record indicates the patient is taking. (JCAHO) The Veterans Healthcare Administration (VHA) has a well established record of using clinical reminders in the outpatient clinics to improve compliance with standards of care (SOC) and guidelines. (Patterson 2005) To ensure compliance with this new JCAHO standard, the Veterans Administration Maryland HealthCare System (VAMHCS) in Baltimore, MD, recently added the Medication Reconciliation Clinical Reminder (MRCR). The current implementation of the MRCR is unlikely to be successfully utilized because it disregards the barriers of poor usability, workflow, and training. (Saleem 2005, Patterson 2004)
Clinicians apply the scientific method of observation, hypothesis, experiment, and results when caring for patients. For example, the Licensed Independent Practitioner (LIP) notes that the blood pressure is above desired limits and the patient is taking medications (observation). A medication is changed (hypothesis that this will lower the blood pressure) and the patient’s blood pressure is monitored for a response (experiment). The results are observing if the new blood pressure is below the predetermined limit. Having a complete knowledge of all of the medications being taken, previously taken or tried, and those that caused adverse events is paramount to deciding what medication change to test. Usually a significant amount of time is devoted to this reconciliation during the patient encounter although documentation of its being completed may not be reflected in the record. The MRCR is intended to improve the documentation of the reconciliation event.
Many of the VHA’s clinical reminders (CRs) are straight forward and can be completed after reading though them the first time without much difficulty. Those that have multiple components can be confusing. Historically, those pieces of the reminder that are required to be addressed to satisfy it are tagged with an asterisk. In its current form the MRCR is cumbersome at best as elicited by the sequence of events to complete the MRCR described in the next paragraph.
To address the MRCR, the LIP first needs to click on the CR to open it. In the new window, several boxes with asterisks are presented that may need to be checked. Depending on the reconciliation, up to four of these may actually need to be checked with the changes entered as free text. Next the clinician needs to check a box attesting that the patient was given a copy of the list. Finally, a box needs to be checked to attest that the patient understood the directions. In addition to the reminder, the actual orders for these medication changes need to be entered in the orders tab, which requires another two clicks to access it. Patterson (2004 p195) reports “…ease of use issues contributed to difficulty in using clinical reminders…multivariate regression found that a “perceived utility and ease of use” scale compiled from composite variables was positively associated with the number of implemented reminders.”
The MRCR is added to several CRs that may be due for each patient at each encounter. The CR in its current format. Saleem cites workload as one of the five barriers to the providers using clinical reminders. “Completing the CR creates ‘double documentation’ burdens…when CRs require redundant data entry this is a barrier to effective use…” (Saleem 2005 p442) Another component related to workload is time. “…providers reported the CRs as being ‘time-consuming’…the CRs are less likely to be satisfied when they are pressed for time.” (Saleem 2005 p442) Patterson (2004 p55) notes “All sites reported that a significant barrier was the lack of time to follow documentation procedures within the CR…” Furthermore, according to Saleem (2005 p444), “A physician champion for reminders informed us that they had explicitly decided to keep the overall number of reminders down to reduce ‘reminder fatigue’.”
With neither warning nor prior training the new MRCR appeared in the drawer of CRs as due for each patient. The first pass through for the LIP was into unfamiliar territory. If the LIP completed the MRCR and refreshed the patient record, the MRCR would still show as being due. This created confusion that something might have been missed in the first attempt. Unbeknownst to the LIP, the MRCR is designed to never resolve because medication reconciliation is expected to be performed by all LIPs at each encounter where the patient transitions in the system. This includes admission to, transfer within, and discharge from the hospital as well as each visit to an LIP in an outpatient setting. Patterson (2005 p194) reports that “Insufficient training contributed to difficulty in using clinical reminders…” and that 22% of clinicians surveyed indicated that formal training helped them to incorporate clinical reminders in patient care.
Computerized clinical reminders
"Computerized clinical reminders (CRs)…are designed to improve quality of care by reducing reliance of healthcare providers on their memory and by presenting accepted clinical guidelines at the point of care." (Saleem 2007 p632) The VAMHCS introduction of the Medication Reconciliation Clinical Reminder is intended to satisfy JCAHO’s new standard for ensuring accurate knowledge of the patient’s medications. While it is not a traditional clinical reminder, it is implemented as one. Because the clinicians were not given training on how to complete the reminder prior to its rollout, the intensive effort that is required to work through the reminder, and that it is an additional volume of work required to be completed in the same amount of time per patient encounter, this new Medication Reconciliation Clinical Reminder is not likely to be successfully utilized. It is this author’s opinion that significant revision will be needed to make this CR fit easily into the busy clinician’s workflow and also allow the administration to track the clinician’s documentation of the patient’s medication reconciliation.
- Jason J. Saleem, PhD, Exploring Barriers and Facilitators to the Use of Computerized Clinical Reminders, J Am Inform Assoc. 2005; 12:438-447. DOI 10.1197/jamia.M1777
- Jason J. Saleem, PhD, Impact of Clinical Reminder Redesign on Learnability, Efficiency, Usability, and Workload for Ambulatory Clinic Nurses, J Am Med Inform Assoc. 2007;14:632-640. DOI 10.1197/jamia.M2163
- Joint Commission on Accreditation of Hospital Organizations 
- Emily S. Patterson, PhD, Human Factors Barriers to the Effective Use of Ten HIV Clinical Reminders, J Am Med Inform Assoc. 2004;11:50-59. DOI 10.1197/jamia.M1364.
- Emily S. Patterson, Identifying barriers to the effective use of clinical reminders: Bootstrapping multiple methods, Journal of Biomedical Informatics 38 (2005) 189-199
Author: Michael Lees, M.D. February 22, 2008