Medication reconciliation

# Overview
Medication reconciliation is "the formal process of obtaining a complete and accurate list of each patient's current home medications including name, dosage, frequency, and route of administration, and comparing admission, transfer, and/or discharge medication orders to that list. The reconciliation is done to avoid medication errors." Medication reconciliation may involve determining a "Best Possible Medication History" (BPMH).
Older adults have difficult in accurately recalling their medications.

# Definitions
- IHI: "the process of creating the most accurate list possible of all medications a patient is taking"
- CMS: "identifying the most accurate list of all medications that the patient is taking"
- Joint Commission: "a clinician compares the medications a patient should be using (and is actually using) to the new medications that are ordered for the patient and resolves any discrepancies."

# Epidemiology

## Frequency of reconciliation errors
In the inpatient setting, the following rates of medication errors have been found:
- Discrepancies 17%, 44%, 46%, 60%
- Inappropriate choice by STOPP/START criteria: 48% 
Although not an error, a related problem is the increase in medication intensity at the time of discharge from the hospital.
In the outpatient setting, the following rates of medication errors have been found::
- Discrepancies 44%, 76%, 83%, 88%
Regarding specific errors, a study of inpatients found:
- Discrepancy with discharge summary: 34%
- Duplicate medications: 23%
- Extraneous medications: 14%
- Medications by indication or disease: 25%
- Medication omission 17%

## Frequency of harm from reconciliation errors
Several studies report rates of complications from medication errors. It is unclear how many of the problems identified in these studies would be avoided by successful medication reconciliation.
In the first study, 851 patients diagnosed with ACS or CHF were assigned to either pharmacist-assisted medication reconciliation, low-literacy adherence aids, and individualized telephone follow-up 1-4 days after discharge or no intervention.
- 432 (50.8%) of subjects had clinically important medication errors. 22.9% of such errors were considered serious and 1.8% life-threatening.
- 258 patients (30.3%) had adverse drug events and 253 patients (29.7%) potential adverse events.
In the second study, 510 heme/oncology patients scheduled for infusion center appointments without a provider visit had medication reconciliation by a student pharmacist. The pharmacists found:
- 88% of patients had at least one discrepancy identified in their medication history and corrected in the EMR.
- 11.4% of patients had a medication-related problem identified, including drug-drug interactions, untreated indications, adverse drug reactions, and untreated indications.
Among outpatients in 6 safety-net clinics in 3 states, discrepancies between patients' reports of medications and the medical record were associated with low hypertension control..

# Methods

## Criteria for determining a medication problem
One proposed criteria is the "number of unintentional medication discrepancies per patient." Because this measure requires a trained pharmacist to assess the gold standard, the authors of the measure suggest that "25 patients are sampled per month, or approximately 1 patient per weekday". Problems with this proposal include unclear criteria used by the pharmacist and that measurement can not be automated or measured in the data routinely collected during patient care.
A medication reconciliation executed by a pharmacist may take over two hours.; however, in the clinic a physician may have less than a minute to discuss medications.

### Specific criteria
A study in the Washington DC VA proposed specific criteria for a medication reconciliation. It included internal medicine residents rotating through the hospital, using bi-monthly educational sessions directed by faculty/chief residents based on accuracy of discharge medication reconciliation. While some of the criteria showed significant change after an intervention, the reliability of these results were not tested. The criteria used were:
- Medication duplicates
- Extraneous medications. In other studies, this is also called one-time medications, post-acute medications, or time-limited medications.
- Discrepancies from discharge summaries
- Omissions
- Grouping medication by indication or disease
Specific criteria for determining a successful medication reconciliation have also been developed by an interdisciplinary team at National Jewish Health (Denver) in an ambulatory practice serving patients with respiratory and related diseases. This study assessed performance in medication reconciliation by the process of comparing patients medication lists at clinical transition points and demonstrated improvement in an outpatient setting, sustainable and valid measures are needed. Across 18 months
- Electronic attestation that med rec was completed at clinic visits increased from 9.8% to 91.3% (p < 0.0001)
- Medication duplication decreased from 4.0% to 2.6% (95% CI: 2.4%2.8%) (p <0.0001)
- Significant improvement was noticed in missing doses, their frequencies
- Provision of medication safety handout with the patients medication lists
An additional finding in the study was that compliance remained a limiting factor in this study secondary to poor-buy in by participants due to redundancy of process.

## Role of patient engagement and understanding
Elderly patients have much trouble understanding changes in medications.
Low health literacy is associated with discrepancies.

## Role of regional health information exchanges
Use of data provided by a regional health information exchange has been advocated. However, the clinical benefit of using a health information exchange is not established. A randomized controlled trial found no reduction in adverse drug reactions.

# Quality measures
Medication reconciliation is a quality measure for Centers for Medicare & Medicaid Services (CMS), it is also a quality measure for National Committee for Quality Assurance (NCQA).

# Public reporting
Medication reconciliation is part of the Centers for Medicare & Medicaid Services's (CMS) EHR Incentive Programs for the Measingful Use Stage 1 and the 2017 Modified Stage 2 Meaningful Use Program Requirements.

# Interventions to promote successful medication reconciliation
Medication reconciliation, as an isolated intervention, may not be effective.
Medication reconciliation at time of hospital discharge alone is insufficient for prevention of hospital readmission although subsequent emergency department usage may be reduced.
When medication reconciliation is combined with follow up phone calls, there is conflicting evidence of benefit with regard to hospital re-utilization after  discharge. Trials report both benefit and no benefit. Comparing the studies,benefit is more likely when multiple, scripted phone falls are made,with patients bringing their medication to the phone.
Multi-factorial interventions that include medication reconciliation may decrease hospital readmissions.