Medication Reconcilliation Mock-Up

James J. Cimino, M.D
Columbia University Department of Biomedical Informatics


Medication reconcilliation (MR) is a task in which the continuity of a patient's medications are addressed during transitions in care. MR is important during all transitions, including transfers of care between outpatient settings, transfers of care between inpatient settings, and at the time of discharge from the inpatient to the outpatient setting. However, one of the most common places where errors occur is at the time of hospital admission. Typically, at the time of admission, a medical history is taken from the patient, or from the patient's caretakers, by the health care provider admitting the patient. The history includes the medications that the patient is supposed to be taking and the last time each medication was taken. This history is supplemented by reviewing available medical records and communicating with the patient's other healthcare providers. The provider then documents the medication history and writes admission orders, including medication orders, for the patient. Quality MR requires that the history is accurate, that the documentation reflects the history as collected, that the plan documents how these medications are being considered (whether it be to continue them, change them to some other medications, hold them temporarily, or discontinue them), and appropriate medication orders are issued to reflect the plan correctly.

There are many challenges to the MR process: an accurate history may be difficult to obtain and there are many points at which errors can creep into the transcription, recording, documentation and ordering processes. Computer-assisted methods are often proposed for assisting with MR. Computer systems can help provide an accurate history by retrieving patient medication information, keeping track of the process so that no medications are forgotten or mistranscribed, and assisting with workflow issues such as documentation and order entry. However, care must be taken that a system that introduces new, necessary parts to the process, such as review of additional data sources and entry of additional documentation (such as "reason for not continuing" a medication), does not make the MR process more onerous and thereby have negative effect on the quality of care. For example, if a system requires precise provider entry of all outpatient medications and then requires precise order entry, the amount of work will be increased, without any improvement in ensuring medications the patient is actually taking are accounted for. There is a difference between saying "I have ordered all the appropriate medications as documented on the patient's medication history" and saying "I have ordered all appropriate medications based on the patient's medications prior to this admission.

The solution proposed here is one that exploits the available data sources to supplement the provider's construction of an accurate medication history and then uses the history to assist with the documentation and order entry tasks. The demonstration is merely a mock-up of a proposed system. It starts with a physician admission note template (from e-Note) that has been modified with a "MedRec" button. The button displays a mock-up of a screen that could actually be generated by extracting various data sources from the Clinical Data Repository (CDR). In some cases, these data are present as coded data, while other parts are present in text reports. The proposed system would use a natural language process system (MedLEE) to convert this latter information to coded form as well.

Once in coded form, the user can select those medications he believes are currently part of the patient's outpatient medication plan. The list can be supplemented with additional history obtained from the patient and the patient's caregivers. In addition to selecting the medications for inclusion in the patient's history, the user can document the last dose of each medication and indicate which medications should be ordered for the inpatient admission. The user is given the opportunity to review the list and document reasons for discontinuing medications. The user can then submit this information to be included in the admission note medication history, the admission note plan, and the inpatient ordering system. The demonstration simulates the workflow and the effect of the process on various systems.

Although this demonstration is merely a hyperdocument consisting of static Web pages, much of the technology is in place to accomplish the MR process it illustrates. e-Note is currently in use and could easily include an MR link. An MR application could readily obtain coded information from the CDR. Some work would be needed to assure the accuracy of coding carried out by MedLEE, but this can be readily accomplished (see Cimino, et al. Medinfo 2007). The output of the MR system can easily populate parts of the e-Note-generated document, in order to improve admission history and documentation of admission plan. The major challenge will be in passing the selected outpatient medications and automating, to the extent possible, the transfer of these medications into the order entry system. Some manual assistance to the process will likely be required, but the impact on workflow should be less than that required when history taking, plan documentation, and order entry are carried out separately, with an increase in accuracy as the system retrieves supplementary patient information and helps to manage the list so that that all medications are accounted for through the entire process.