The elderly and chronically ill patients are typically challenged with many drugs and complicated dosing regimens, often leading to medication errors. Medication errors are one of the most common patient safety events. More than 40 percent of medication errors are believed to result from inadequate reconciliation in handoffs during admission, transfer, and discharge of patients. 

While understanding and reconciling drugs after discharge from the hospital can be challenging, it is a necessity for greater efficacy of care delivery. There can be instances where a patient taking Glucophage before admission and then prescribed Glycomet post-discharge is unaware that the two drugs are the same and continues to take both until the patient's care provider reconciles them. A significant number of emergency admissions are also traced back to insufficient reconciliation.

Medication reconciliation is about identifying the most accurate list of currently prescribed medicines, including the drug's name, dosage, frequency and route. It can be a very time-consuming process involving reviewing all medicines taken by the patient, including home medications, OTC, herbal supplements and prescription medications, and checking them for duplications, dosing errors, omissions and possible drug-drug interactions. 

Various quality programs have mandated medication reconciliation at all events of admission, discharge, transfer, or during regular patient visits to the physician.

Quality programs for tracking medication reconciliation 

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has mandated reconciliation during each patient encounter. Proof of medication reconciliation done within 30 days of discharge is a must for compliance with many regulatory reporting measures, including HEDIS and MIPS MACRA. For value-based care, proof of 30-day medication reconciliation is required to claim incentives against the measure. The Quality Payment Program offers MIPS-eligible clinicians up to 10 percentage points toward the Advancing Care Information performance category score for accurate medication reconciliation and establishing the "Promoting Interoperability" measures. As a part of the improvement activities, 15% of the final score can come from the improvement activities tracked for 90 days.

Identifying prescribed medicines and reconciling them with HL7 FHIR

While the intent of medication reconciliation has always been there, the earlier days of the EHR had screens where home medications had to be manually entered in one column and painstakingly reconciled with the current medicines. Providers would post a Category II CPT code on a claim to attest for reconciliation, usually not paid by the payer and written off by the provider. Physicians faced challenges in reporting for medication reconciliation because of the cumbersome processes. 

The workflows surrounding medication reconciliation are easier to streamline with FHIR resources. The data artifacts are saved in the EHR when a physician has evaluated and attested to reconciled drugs. This workflow has been laid out in detail by the HL7 Da Vinci project.

The HL7 Da Vinci Project is a collaborative effort between payers, providers, technology vendors and interoperability experts to solve real-world challenges by creating solutions that may be implemented to address specific use cases. Medication reconciliation post-discharge is one of the use cases that this group has identified as a high priority one.

Data points to report for medication reconciliation and the corresponding FHIR resources

From a data exchange standpoint, the provider is the data producer, and the payer is the data consumer. Once the primary care physician or treating physician is aware that the patient is within a 30-day post-discharge window, they should review all of the patient's medication lists – pre-admission, during admission and post-discharge – and reconcile them.

This is done through a screen within the EHR that provides all the lists and allows the physician to cancel, add, delete or make necessary dosage adjustments on the prescription to reconcile the meds. Once that is done, the physician attests to having reconciled the medications. The EHR assembles all the FHIR resources used to streamline the complete workflows for medication reconciliation and creates the Measure Report. 

The Measure Report is a specialized FHIR resource that helps organize and contain the results for calculating the measure. This is an effective method to harmonize and package all the information to calculate a quality measure, typically the numerator, denominator, exclusions and inclusions, and the algorithm/calculation steps to generate the results. For the end user, it is an opportunity to remove implementation complexities and organize the information in a structured format. It just helps arrange the necessary resources or datasets already in the EHR and pull them together for reporting purposes.

The primary resources used for defining a Measure are listed in the table below. These are packages of information used to build an algorithm and constructed as a Measure Report by the EHR system when the provider attests to reconciliation.

This constructed report or the Measure Report is received by the FHIR server of the payer and validated. The payer system on validation stores the member's information in their database.

Payer systems can choose to store the data in FHIR or any other proprietary format. The payer, who is the aggregator of the reports, can send out individual patient reports of reconciliation or summary reports to regulatory bodies by sending REST API calls to the receiver of the information, which is usually the NCQA, CMS or any regulatory body. Medication reconciliation is a critical safety practice that helps eliminate situations like duplication, dose errors and drug interactions. The primary care physician's involvement is unquestionably significant in completing the reconciliation.

Dr. Joyoti Goswami is a principal consultant at Damo Consulting, a growth strategy and digital transformation advisory firm that works with healthcare enterprises and global technology companies. A physician with varied experience in clinical practice, pharma consulting and healthcare information technology, Goswami has worked with several EHRs, including Allscripts, AthenaHealth, GE Perioperative and Nextgen.