Medication Reconciliation Technology to Improve Quality of Transitional Care

Study Overview
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Brief Summary
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This study addresses the problem of inadequate medication reconciliation as patients cross boundaries between inpatient and outpatient care (ambulatory care). The purpose of this study is to determine whether a new, computer-based application, integrated with electronic prescribing, improves erroneous discrepancies between pre-hospital medications and medications upon patients' return to ambulatory care.

Detailed Description
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This project will test a systems-based intervention of the electronic medical records system. The specific aims of this study are to integrate a new electronic medication reconciliation (MR) system with an electronic prescribing system, conduct a randomized controlled trial of MR, and determine whether electronic facilitation of MR alters MR and the incidence of medication errors in ambulatory care. On a patient's hospital admission, a new Web-based MR module will receive an automatically compiled outpatient medication list. Following discussion with the patient, medical personnel will update the list, which will then be delivered to the computer-based provider order entry system and become actionable for prescribing. Main outcomes include adverse drug events and erroneous discrepancies between the pre-admission medication list and the medication list upon the patient's return to ambulatory care. We hypothesize that electronic facilitation of inpatient MR will improve completion of MR and will decrease the incidence of drug-related medical errors.

Official Title
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Medication Reconciliation Technology to Improve Quality of Transitional Care

Conditions
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Medication Reconciliation

Intervention / Treatment
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* Other: Electronic medication reconciliation


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Patients admitted to the Medicine Service during a 12-month period Physicians who provide inpatient or ambulatory care for participating patients. Pharmacists who provide care for participating patients. Exclusion Criteria: Patients admitted but not seen in a primary-care clinic within the preceding 12 months If an enrolled subject is determined to be a prisoner or pregnant woman, then the study will discontinue the subject for research purposes or will submit an amendment at that time.

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Electronic medication reconciliation<br>Providers have access to a new, computer-based application to facilitate documentation and prescribing of outpatient medications in the inpatient setting. | Other: Electronic medication reconciliation<br>* A new, computer-based application will be used to document and prescribe outpatient medications in the inpatient setting.<br>* Other names: MedMatch;|
| No Intervention: Control<br> | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Reconciliation of outpatient medications | Number and fraction of outpatient medications prescribed or addressed as to why prescribing did not occur. Number and fraction of cases with MR by a pharmacist. Number and fraction of cases undergoing any MR. Number and fraction of cases where any outpatient medications were not prescribed or addressed as to why prescribing did not occur. | Hospital admission, transfer, and discharge; 1 year | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Measurement of potential for harm and potential severity of harm | For each medication discrepancy, the study team will reach consensus about potential for harm and potential severity of harm. The study team will adopt the following framework: little or no confidence (e.g., omission of multivitamin); slight to modest confidence (e.g., docusate 200 mg every morning, instead of 100 mg twice daily); less than 50% chance but close call (e.g., omission of as-needed enema at discharge); more than 50% chance but close call (e.g., omission of fluticasone twice daily at discharge); or strong confidence (e.g., omission of as-needed haloperidol). | Hospital discharge; 1 year | 
| Measurement and analysis of providers' perspectives | We will conduct a before-and-after survey of providers. Providers will be surveyed about satisfaction with care, managing medications, and usefulness of local information systems in managing medications. | Start and end of trial; 1 year | 
| Measurement and analysis of patients' perspectives | The inpatient geriatrics consultation service has begun calling patients who received geriatrics consultation and were subsequently discharged to home. The calls are made by telephone within 72 hours of discharge. Patients are asked eight to ten questions, addressing satisfaction with care, receipt of information about medications, and adherence to medications. | Hospital discharge; 1 year | 
| Reportable financial and organizational dimensions | We will track and report hours required for several parts of the development and implementation, as follows: hours required for new technical development; and hours providers spend in learning about system and how to use it. | Start of trial; time 0 and 1 year | 
| Utilization of intervention | Fraction of intervention admissions for which Web-based medication list was reviewed or modified. Mean duration of use of Web-based application. Fraction of intervention admissions, transfers, and discharges for which new medication list was used to order medications. Fraction of medications on medication list that were ordered on admission, transfer, and discharge. Timing of when medication reconciliation occurred. | Hospital admission, transfer, and discharge; 1 year | 
| Measurement and analysis of drug-related medical errors | At discharge, we will assess for unintentional medication discrepancies at discharge. At ambulatory followup, we will assess whether the medications should have been prescribed at discharge. When a patient is discharged from the hospital and resumes ambulatory care, the patient is expected to adhere to the discharge prescriptions. Each discharge will be reviewed by members of the study team, to determine, for each medication listed on the pre-admission medication list but not prescribed at discharge, whether the discrepancy was intentional or unintentional. | Hospital discharge; 1 year | 
| Measurement of adverse drug events and near misses | We will count deaths and will identify and assess adverse drug events (ADEs). The following kinds of triggers will be used to identify encounters that might reflect ADEs: diagnostic codes for diagnoses associated with ADEs, potential ADEs, or medication errors; use of specific drugs suggesting that an ADE may have occurred; potentially dangerous drug combinations; combinations of drugs and symptoms (e.g., angiotensin converting enzyme inhibitor and cough); combinations of diagnoses and drugs; and combinations of drugs and miscellaneous. | Hospital discharge; 1 year | 
| Medication discrepancies between pre-admission and ambulatory followup | Mean number of erroneous discrepancies between pre-admission and ambulatory followup | Ambulatory followup; 18 months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Medication Reconciliation, Inpatient, Electronic Medical Records