2 May 2016 | Medication Safety
Counties Manukau Health and Northland are among district health boards (DHBs) leading the way in the roll out of electronic medicine reconciliation (eMedRec).
eMedRec is a tool used to document a patient’s medication history prior to admission using two or more information sources – one preferably being the patient or caregiver. The medicines are then matched to the ones that have been charted on admission (and any subsequent transfer of care). Any differences are then electronically reconciled to capture the reasons for medication changes and to ensure there is a safe and accurate record of the patient’s medication throughout their hospital journey.
eMedRec is currently carried out at Counties Manukau, Northland, Waitemata, Taranaki and Canterbury DHBs.
Medication Safety Specialist Pharmacist at Counties Manukau Health, Marie Lewis, says the DHB is one of the first in the country to roll out eMecRec to the majority of their inpatient beds.
“We currently have eMed Rec available in 84 percent of adult inpatient beds – 727 beds. We also have it available in 66 paediatric inpatient beds. This is across Middlemore Hospital and the DHB’s four satellite hospitals – Franklin, Pukekohe, Spinal Unit and the Manukau Surgery Centre. However, eMedRec is not available for the maternity or mental health services because they use different electronic clinical information systems.”
Currently, over 80 percent of high-risk adult inpatients receive electronic medicine reconciliation service during their admission, and 62 percent of all inpatients irrespective of risk.
Marie says when eMedRec began to be rolled out at Counties Manukau, the DHB was already using electronic discharge summaries (EDS) within Soprano Medical Templates, making the introduction of eMedRec at discharge much easier.
“Clinicians were already familiar with the functionality within the EDS so eMedRec was incorporated into their existing workflow which made implementation at the point of discharge easier. Also, it utilises forcing functionality – if the medicines aren’t reconciled within the discharge summary, the discharge summary can’t be finalised.”
She says while eMed Rec has reduced some prescribing errors at discharge it is dependent on the availability of a pharmacist-conducted electronic medication history being completed on admission.
“eMed Rec is only a tool. If you take a poor quality medication history or don’t have a quality medicine reconciliation processes –– medication errors will be populated through the system electronically.”
She says the most common errors that eMedRec processes identify are the omission of medication the patient is taking.
“For example, a patient may have started a medicine recently that they purchased over the counter, or may have changed the number of tablets they take, which is not reflected in the GP or pharmacy electronic systems That’s why it’s so important to always talk to the patient, whānau or caregiver and find out exactly what medicines they are taking.”
At Counties Manukau DHB, pharmacists and doctors work together when patients are being admitted. An example of this collaboration can be seen Monday to Friday, 8am to 10pm for medical admissions triaged from the Emergency Care Department.
“When people are admitted, the pharmacist takes their medication history while the doctor assesses them medically. Then they work together to review the medicines for the patient and complete the reconciliation.
“This means potential errors are stopped ‘at the front door’. And the doctors I’ve talked to – particularly the new doctors – say they’ve learned so much about the clinical impact of medication from working with pharmacists.”
Marie says another advantage of eMedRec is it speeds up the discharge process.
“When a doctor is doing a discharge summary, and eMedRec has been completed on admission, the medicines the patient was on before they came in to hospital and any changes that occurred during the admission pre-populate the discharge summary.
“eMedRec also improves communication between hospital doctors, general practitioners and community pharmacists, and between clinicians and their patients. It is accessible at any clinical workstation through the hospital or internet portal for the community teams.
“For example, in the past, the discharge summary had details of new medicines being prescribed, but not always why they were prescribed, or why a particular medicine originally prescribed by the GP may have been stopped or had a dosage change.”
“With eMed Rec, reasons for any changes to medicines are mandatory, and this information automatically goes to the GP on discharge. This information is also embedded within the discharge script for the community pharmacist and the patient medication card, which can be used to discuss medication changes with the patient at discharge.”
Marie says while eMedRec has huge benefits, there’s definitely room for improvement.
“The version we currently use doesn’t have much clinical decision support. This would be a valuable area of development to help prevent some prescribing errors occurring at the point of discharge. It is also being upgraded to incorporate the NZ Universal List of Medicines, to enable searching for all medicines available in New Zealand, whether they are registered or not. We are also hoping the upgrade will solve some of the workflow inefficiencies caused by eMedRec not working well across different services and transfers of care.”
Marie’s message to other DHBs introducing eMedRec is to take the time to get your processes right and involve the right disciplines with the best skill mix, in the areas near the start of the patient’s journey for the patients that would benefit most.
“We have an eMedRec process Key Performance Indicator incorporated into our Patient Safety dashboard for the organisation to highlight it as a priority. However, if the quality of the processes are not monitored you may reach the target KPI but have little impact on preventing medication errors.
“Tips for implementation include getting it right as early as possible in the patient’s journey, prioritising patients with a high risk of medication harm and making sure you have quality processes, and then spread to other areas and types of patients.”
eMedRec important quality improvement tool for Northland DHB
Northland DHB Senior Clinical Pharmacist Harriet Sands says the DHB introduced eMedRec in 2014, and it is an extremely important quality improvement tool. It is carried out by hospital pharmacists when a person is admitted to hospital.
“Once eMedRec has been performed, a person’s medication history can be viewed electronically from a number of different places – by community and hospital pharmacists, GPs and hospital doctors.
“Pharmacists also have better information and a better relationship with the patient because of the time spent with them.”
Harriet Sands says eMedRec also makes things easier for doctors, because the patient’s medication information is there electronically when they come to discharge.
eMedRec is a high priority for the DHB, which included the process in its 2014 Quality Accounts.
“We had a target of 70 percent of newly admitted adult patients on the surgical, medical and stroke wards having eMedRec each month,” says Harriet. “We restructured the team approach to eMedRec so we would meet that target, which we did most of the time.”
She says eMedRec at admission is prioritised for patients who are 65 years and over or 55 years of age if they are Māori or Pacific.
“A report comes into pharmacy saying which wards priority patients are on. This saves a lot of time in scrolling through the ward lists to identify them. We then go to see the person and undertake eMedRec.”
Harriet says while eMedRec has a number of benefits, there are also drawbacks.
“eMedRec reduces errors but it doesn’t make things quicker. For example, loading a patient’s medication history from Testsafe can be slow – leaving less time for other tasks.
“Also, even though eMedRec is being done at admission, reconciliation is not always completed by the prescribers. This is likely to be because medicine charts are paper-based while MedRec is electronic. So information needs to be altered on the paper charts and the electronic system, but this doesn’t always happen.”
However, she says on balance, eMedRec’s role in safety and improving the visibility of medicines-related information and communication between health professionals makes it a very valuable tool – and one she encourages other DHBs to take advantage of.
“It shows discrepancies and the importance of a concentrated effort on medication management and also is an enabler for discharge reconciliation, readmission information and highlights the value of pharmacist intervention.”