Emergency departments are by nature fast, hectic environments where clinical decisions need to be made quickly, often with limited information. Patients may be unconscious or unable to communicate, making manual or verbal confirmation of a patient's home medication list challenging.

THE PROBLEM

"A peer-reviewed study, Unintended Medication Discrepancies at the Time of Hospital Admission, investigated the potential for adverse drug events as a result of inaccurate medication history and found that up to 70% of patients have errors on their medication list when admitted to the hospital through the ED, and up to 59% of these errors can cause harm," said Rachel Blum, clinical pharmacy manager at South Shore Hospital in South Weymouth, Mass.

In 2021, South Shore Hospital prioritized efforts to reduce costly ADEs and potential readmissions that commonly come from patients admitted through the ED. With more than 300 patient visits per day to the ED, and a third of those patients routinely admitted, the staff understood that improving the process and tools clinicians use to gather a patient's medication history could address some major sources of organizational pain – such as preventable ADEs and potential hospital readmissions – and could improve patient safety.

PROPOSAL

South Shore Hospital selected health IT vendor DrFirst's MedHx solution to help. It provides a combination of local and national medication history sources directly within the hospital's native Epic EHR workflow for a more comprehensive database of medication history than the hospital was receiving from the standard industry feed.

Along with providing data from health information exchanges and other EHR partners, DrFirst would identify and connect with local pharmacies that share mutual patients to make the dispensed prescription fill information available to South Shore as part of the MedHx solution.

"The vendor's SmartSuite adds another layer of clinical workflow support with artificial intelligence that normalizes prescription instructions, known as sigs, into consistent terms, safely infers missing information, and prepopulates drug and sig information within the Epic EHR, so our clinicians wouldn't need to manually enter medication information," Blum explained.

"DrFirst also offered MedHx Companion to give us clinical insights into patients' medication histories," she added. "Just as a spreadsheet of raw data doesn't provide the same level of insight as a dynamic chart or graph, MedHx Companion takes the medication history data provided within the Epic workflow and visualizes it in a web-based application to reduce our staff's cognitive effort."

To ensure pharmacy technicians focus their efforts on high-risk patients, South Shore staff created a patient complexity score embedded in the EHR to help identify and prioritize medically complex patients and allow these patients to be evenly distributed across the pharmacy team. The DrFirst clinical team was available to work with South Shore staff to quantify how this new method affected clinical outcomes.

MEETING THE CHALLENGE

South Shore's nursing department previously had responsibility for gathering and confirming a patient's medication list, but balancing that responsibility alongside their other duties was problematic and could potentially lead to errors.

Formally assigning ownership of gathering medication history to the pharmacy department was a logical first step in reducing errors, ensuring safer transitions of care and maximizing ED staff productivity, Blum said. The hospital now has a team of 19 pharmacy technicians supporting four ED pharmacists from 6 a.m. to 11 p.m.

"We implemented DrFirst technology in our Epic EHR to support the team's process of gathering and confirming a patient's medication history," she said. "MedHx provides more complete medication history data, reducing the time our staff has to spend calling pharmacies and providers to gather and confirm that information.

"We also implemented MedHx Companion to view patient medication history in a web-based, visual timeline," she continued. "This gives our clinicians a quick view of adherence gaps and prescription fill meters, along with the ability to sort by drug class. Map views let clinicians identify potential opioid abusers seeking prescriptions from multiple providers across state lines."

And because MedHx Companion is not part of the EHR, the pharmacy team can find patients before admission, by alternate spelling, or by ZIP code. Pharmacy technicians find this beneficial when trying to complete these patients' medication histories as quickly, accurately and efficiently as possible, she said.

RESULTS

With MedHx and SmartSuite installed, South Shore Hospital pharmacists and pharmacy technicians are now finding clinically actionable medication history on 91% of patients queried, Bum reported.

Along with prioritizing high-risk patients, in the first five months the staff found these additional high-risk medications beyond what they would previously have received from other sources:

• 7,712 abuse-related medications
• 2,962 cardiovascular medications
• 1,515 thyroid disease medications
• 1,499 anticonvulsants
• 1,274 steroids and immunosuppressants
• 946 antipsychotics
• 598 diabetic therapy medications
• 169 anticoagulants

ADVICE FOR OTHERS

Hospitals are facing increasing scrutiny and legislation on how to actively manage high-risk patients to reduce ADEs and readmissions. South Shore Hospital staff recommend three steps to address the most critical issues that affect the medication history process within the ED:

Step 1: Put the best people in place to gather and confirm a patient's medication history. Some states are requiring pharmacists and pharmacy technicians to obtain an accurate medication profile or list for each high-risk patient upon admission of the patient.

Step 2: Use medication management technology to provide the most complete patient data possible to reduce errors, save clinicians time and give clinicians multiple sources to uncover critical details that can help prevent serious ADEs.

Step 3: Help maximize pharmacy staff resources by prioritizing the most medically complex patients to ensure these patients receive the highest quality of care and prevent them from being readmitted to the hospital. To ensure that pharmacy technicians focus efforts on all high-risk patients, South Shore Hospital created a patient complexity score embedded in the Epic EHR. This helps identify and prioritize medically complex patients and allows them to be evenly distributed across the pharmacy team. Staff built the complexity score on key factors such as:

• age
• active problems (such as congestive heart failure, diabetes, COPD and pulmonary hypertension)
• high-risk medications on the prior-to-admission list (such as warfarin, immunosuppressives, anticonvulsants and antiplatelets)
• whether the patient has been assigned a provider
• whether a medication history consult has been requested

"The higher number of points assigned to the patient, the higher they rank on the pharmacy team's priority list," Blum explained. "The lead medication history technician is the 'air traffic controller' who uses this data, as well as the medication history work queue, to prioritize patient order and which technician will perform the medication reconciliation.

"Our goal is to review the medications of our most medically complex patients first, and then work our way through other admitted patients as time allows," she concluded. "By prioritizing patients by their complexity score, we are increasing medication safety and improving clinical outcomes."

Twitter: @SiwickiHealthIT
Email the writer: bsiwicki@himss.org
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