The recently signed health care reform bill was passed through a process called reconciliation. This was a bit controversial politically, because the unified Republican opposition wanted to prevent the bill from becoming law. In this context, reconciliation meant negotiating a compromise to the House and the Senate versions of the bill through budget negotiations to achieve implementation of the law.
Medication reconciliation is altogether different, in that there’s no controversy. We ALL need to be doing it, according to JCAHO (the Joint Commission on Accreditation of HealthCare Organizations, pronounced “Jay-co”) the IHI (Institute for HealthCare Improvement, brainchild of Dr. Donald Berwick, recently appointed-but-as-yet-unconfirmed head of CMS, the government’s Medicare and Medicaid entity), and virtually every other person and organization involved in improving the quality and safety of health care for patients.
Reconciling medication seems too basic to even think about, but it’s a much more complex task than it appears at first glance.
What is it?
When a patient, let’s say for example someone named “Nancy,” is admitted to the hospital, there’s a pretty good likelihood that she’s already taking some daily medications for one or more chronic conditions. Think of a top five that might spring to mind:
- High blood pressure (“hypertension”)
- Heart Disease
- Reflux (“GERD”)
Each of these conditions are common in the general population (you or someone you know has at least one), and are usually managed with at least some medication in pill form. Of course, individuals and the medications they’re on will vary.
And that’s precisely the point.
Let’s say “Nancy” is 65 or older. If so, she’s likely on three daily prescription medications, and if she’s older or has more than one of these conditions, the number of daily pills can easily rise to double digits.
She comes to the hospital. She’s interviewed and examined by a nurse; then by a doctor (or three, depending on whether the hospital in question is a teaching hospital or not).
“What medications do you take?” Nancy is asked not one but two or more times.
Does she provide a list or printout of her medications? Does she recall them by name and dosage? Or does she, like millions of Americans, say “I take the blue one for my blood pressure and the pink one for my reflux.”
This may surprise you, but doctors have NO IDEA what the pills we prescribe look like. Telling us the pill color or pill size is a surefire recipe for at least misunderstanding and at worst disaster (as in we give Nancy the wrong pill, or omit the correct one, leading to harm).
Let’s hope Nancy carried her pill bottles with her, a smart move because then they can be catalogued, in addition to knowing what pharmacy she fills them at. Usually a good idea to call the pharmacy to verify.
Now we’re getting somewhere. The nurse jots down the medication names and doses on his admission form (Nancy has “Dave” as her admission nurse). The intern (a doctor in her first year of training out of medical school) asks what medications Nancy is on, but Nancy tells Dr. Newbie that she’s already answered that question and to “look at what the nurse wrote down.”
Dr. Newbie will likely look at Dave the nurse’s admission form, but if she’s busy with a lot of hospital admissions that night, she might not. If she’s very thorough, she will call the retail pharmacy to verify medications and doses.
You can see where this might start to break down. And this is only the admission.
Each drug has to be evaluated in the context of the reason that Nancy has been admitted. If she’s on metformin for her diabetes, then should she stay on the pill in the hospital or not? We certainly don’t want her diabetes to get out of control while she’s in our hospital, do we?
Nancy was admitted for pneumonia. In addition to some of her “home meds,” (as we call them) she gets started on the hospital’s “antibiotic du jour,” i.e. a go-to drug that we commonly use for common conditions. It so happens that at GlassHospital, like all hospitals, we get bulk discounts on some drugs and told that they’re “formulary preferred.” The problem with this will come later.
Let’s say that all goes well, and Nancy’s pneumonia starts to get better. It’s now approaching discharge time.
Do the doctors reflexively put her back on all of her home medications? This is straightforward for the drugs that she came in on and has continued all along. But what about her heart medicine that was stopped since it lowers blood pressure and the pneumonia itself had caused Nancy’s blood pressure to transiently drop? Do we re-start it right away? Do we wait for her primary care doctor or cardiologist to issue the instruction?
And what about the antibiotics? The hospital’s contract with the newer, more expensive respiratory flouroquinolone (a group of newer and well-tolerated antibiotics that have the advantage of being able to be given only once per day) only covers the medicine while Nancy’s in the hospital.
Makes sense to keep her on the antibiotic she’s on, right? After all, she’s been getting better on it.
But her pharmacy plan does not prefer that drug. In fact, a mere seven days of that one type of pill costs more than one hundred dollars retail!
Time out! Who’s keeping track of all of this? And how? Is it done with a computerized record, or are we relying on the old-fashioned pharmacy printouts (“MAR”= Medication Administration Record)?
Solution: let’s put Nancy on a generic antibiotic, that will work as well as the costly one, and only cost a fraction. Let’s give her clear written instructions about which pills she will take at home, and which of those she came in on that have been discontinued.
The doctors and the nurses need to cooperate, and most importantly, communicate about all of this. Let’s hope that in addition to giving Nancy her discharge papers, on which this is all spelled out so clearly that an eighth-grader would understand it, her family is included in the education and discharge process.
And since she’s returning to the “outpatient” world, let’s hope GlassHospital has a mechanism for transmitting all of this new information to her Primary Care Doctor.
Sigh. A guy can dream, can’t he?