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Service Delivery Innovation Profile

Electronic Medical Record–Based System Featuring "Soft" and "Hard" Stops Significantly Improves Completion of Medication Reconciliation


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Snapshot

Summary

Clinicians at New York Presbyterian Hospital's five inpatient facilities use an electronic medical record–based medication reconciliation system to ensure that they accurately identify and assess the appropriateness of drugs being taken by patients within 24 hours of inpatient admission. The system includes a "soft" and "hard" stop. The soft stop reminds clinicians to perform medication reconciliation whenever they open the patient's electronic medical record during the first 6 to 18 hours after admission. After the 18-hour point, the hard stop prevents the entering of new orders until medication reconciliation has been completed. The system led to rapid, significant, and sustained increases in medication reconciliation adherence rates at all five hospitals.

Evidence Rating (What is this?)

Moderate: The evidence consists of comparisons of adherence rates to on-admission medication reconciliation before and after implementation of the program.
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Developing Organizations

New York Presbyterian Hospital
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Use By Other Organizations

As noted, Bellevue Hospital in New York City uses a medication reconciliation system that includes a hard-stop function.

Date First Implemented

2008

Problem Addressed

The Joint Commission recommends that medication reconciliation—the accurate and complete reconciling of medications across the continuum of care—be performed on hospital admission. Yet, many hospitals fail to perform this task, leading to the potential for serious patient harm due to the omission of needed medications and/or the unintentional duplication of medications. Multiple obstacles account for these low levels of adherence.
  • A common problem, with the potential to cause patient harm: Many hospitals do not regularly perform medication reconciliation on admission. For example, adherence rates at New York Presbyterian's five inpatient facilities ranged between 30 and 82 percent before implementation of this program, with four of the five hospitals having rates below 53 percent. Even in cases where medication histories are obtained, they often contain errors. A recent systematic review found that 54 to 67 percent of admitted patients have at least one discrepancy between the medication history obtained by admitting clinicians and the actual preadmission regimen. The same review found that in 27 to 59 percent of those cases, these discrepancies had the potential to cause harm.1
  • Multiple obstacles impeding adherence: Incorporating medication reconciliation into the daily clinical routine can be challenging at many hospitals, especially large academic medical centers with many residents, faculty members, nurses, and other support personnel. Major challenges include the lack of accepted, standardized processes for performing medication reconciliation (thus, requiring each hospital to develop its own unique plans, processes, and measures of effectiveness); an absence of consistent electronic medical records (EMRs) that span the continuum of care; and time pressures facing busy clinicians.2

What They Did

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Description of the Innovative Activity

New York Presbyterian Hospital implemented an EMR-based medication reconciliation system to ensure that clinicians accurately identify and assess the appropriateness of all drugs patients are taking sometime within the first 24 hours of admission. The system features an initial popup reminder (a "soft" stop) whenever a clinician opens the EMR during the first 18 hours after admission, followed by a "hard stop" that forces reconciliation to occur the next time the EMR is opened. Key elements of the program are described below:
  • Popup, soft-stop reminder to complete reconciliation: Once a patient is admitted to the hospital, clinicians can complete the medication reconciliation at any time through the EMR system. (Two of the five New York Presbyterian facilities use residents to perform reconciliation, while the other three use nurse practitioners, physician assistants, or offsite residents.) Beginning 6 hours after admission and continuing until 18 hours after admission, clinicians see a popup reminder to perform medication reconciliation whenever they open the EMR. In response, they can either perform the medication reconciliation process or close the reminder, with no impact on their ability to enter orders or perform documentation. If the clinician chooses to do medication reconciliation at this time, he or she completes the following three steps:
    • Ordering on-admission reconciliation: The clinician submits an order for medication reconciliation on admission.
    • Performing reconciliation: The clinician performs reconciliation by comparing the patient's home medication list (which contains name, dosage, frequency, and route for both prescription and alternative and nonprescription medications) to currently ordered medications. If needed, discrepancies can be corrected and/or necessary adjustments made.
    • Submitting attestation: As part of the order, the clinician submits an "attestation statement" indicating he or she has completed on-admission medication reconciliation.
  • Hard stop to force medication reconciliation: If no one has performed medication reconciliation within the first 18 hours after admission, the next clinician who accesses the patient's EMR cannot enter orders or document in the patient's chart until he or she completes the medication reconciliation process using the same three steps outlined above.

Context of the Innovation

New York Presbyterian Hospital is a large academic hospital system with five inpatient facilities, including two large teaching hospitals (Weill Cornell Medical Center and Columbia University Medical Center) and three smaller hospitals (Allen Hospital, Morgan Stanley Children's Hospital, and New York-Presbyterian Hospital/Westchester Division). The impetus for this program came from The Joint Commission, which in 2006 began requiring that hospitals have policies and procedures in place related to the performance of medication reconciliation. After putting in place a paper-based system that did not lead to significant improvement, hospital leaders decided to seek more effective options, ultimately leading to the EMR-based "hard" and "soft" stops.

Did It Work?

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Results

The system led to rapid, significant, and sustained increases in performance of on-admission medication reconciliation.
  • Rapid, significant increases in adherence rates: On-admission adherence rates (i.e., the percent of newly admitted patients having medication reconciliation performed within 24 hours of admission) increased quickly and significantly at each of New York Presbyterian's five inpatient facilities. Within 2 months of implementation, adherence rates at its large teaching hospitals increased from 53 to 92 percent at one facility and from 48 to 97 percent at the other. At its 3 other smaller hospitals, adherence rates increased from 30 to 90 percent, from 31 to 93 percent, and from 82 to 100 percent.
  • Sustained improvement: These rapid increases have been sustained over time, with virtually no dropoff in adherence rates at any of the five facilities during the subsequent 4-month period. Six months after implementation, adherence rates at the five hospitals ranged between 91 and 99 percent.

Evidence Rating (What is this?)

Moderate: The evidence consists of comparisons of adherence rates to on-admission medication reconciliation before and after implementation of the program.

How They Did It

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Planning and Development Process

Key elements of the planning and development process included the following:
  • Forming steering group: After the paper-based system failed to achieve the desired results, New York Presbyterian formed an organization-wide, multidisciplinary medication steering group in early 2007. This group took responsibility for creating a strategy to adhere to The Joint Commission's medication reconciliation requirements. Recognizing the need for a fast solution, the group decided to engage frontline providers in developing and implementing a better system in these hospitals.
  • Leveraging physician resident council: In response to the steering group's decision, several residents at Weill Cornell Medical Center decided to leverage the existing Housestaff Quality Council to work on medication reconciliation at the facility. This group invited each department within the medical center to nominate a resident, from any training year, to be a representative to the council. The group met monthly with hospital administrators, information technology (IT) specialists, and other residents to research potential strategies for improving medication reconciliation processes. The steering group agreed that if residents at Weill Cornell proved successful in implementing an effective medication reconciliation system, the same approach would be implemented at the system's four other hospitals.
  • Researching options and choosing approach: The council researched and considered various options for improving adherence rates. One particularly interesting model came from Bellevue Hospital in New York, which implemented the "hard-stop" strategy in 2007. In early 2008, the council agreed to adapt this approach to Weill Cornell's needs. Over the ensuing months, residents on the council worked closely with the hospital's IT staff to integrate the system into the existing EMR system.
  • Preparing for implementation: The council's departmental representatives informed their colleagues of the new system, emphasizing its purpose and the importance of adherence. IT staff held brief training sessions to show residents how the system worked. The council sent e-mails to all residents to reinforce this information, and as a final reminder, sent out a text message via the hospital paging system on the day of implementation to all residents and attending physicians.
  • System rollout and expansion: Several days after implementation at Weill Cornell (which occurred September 30, 2008), it became clear that the system worked well. Consequently, it was implemented at the other four hospitals over the next several weeks. Residents took responsibility for medication reconciliation at the other academic medical center. At the three smaller hospitals (which do not have onsite residents), nurse practitioners, physician assistants, or offsite residents were made responsible for using the EMR-based system to perform reconciliation.

Resources Used and Skills Needed

  • Staffing: The medication reconciliation system did not require the hiring of additional personnel. Hospital IT staff developed the software, incorporated it into the existing EMR system, and provided training as part of their regular jobs. Similarly, medical residents and other clinicians incorporated the system into their daily work routine.
  • Costs: Program costs are minimal because the new system has not required the purchase and maintenance of additional equipment.

Tools and Other Resources

The Joint Commission. Using medication reconciliation to prevent errors. Sentinel Event Alerts, Issue 35, Jan 25, 2006. Available at: http://www.jointcommission.org/sentinel_event_alert_issue_35_using_medication_reconciliation_to_prevent_errors
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The Joint Commission. National Patient Safety Goal on Reconciling Medication Information. Available at: http://www.jointcommission.org/2012_npsgs_slides/

Adoption Considerations

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Getting Started with This Innovation

  • Involve end users in choosing and implementing model: Depending on the hospital's size and type, different staff may be responsible for medication reconciliation (e.g., attending physicians, residents, nurses, pharmacists, or some combination of individuals). Staff responsible for reconciliation will be much more likely to support this program if they (or their direct representatives) have input into choosing the approach and how it will be implemented (rather than having it mandated by hospital leaders).
  • Include a hard stop: Medication reconciliation systems that do not at some point require users to input the required information are likely to fail because staff may choose to ignore voluntary reminders for a number of reasons (e.g., time pressures, resentment of the additional responsibility, lack of understanding of the task's importance).

Sustaining This Innovation

Share successes: Once adherence rates have risen to an acceptable level, begin sharing performance data on a monthly basis to relevant staff via e-mail and the posting of charts in staff lounges. Providing this information serves as an incentive to maintain and improve performance.

Use By Other Organizations

As noted, Bellevue Hospital in New York City uses a medication reconciliation system that includes a hard-stop function.

Additional Considerations

Program developers indicate that official adherence rates have not reached 100 percent in all facilities because in a few cases, no clinician opens the patient's EMR during the 6-hour time window when the hard stop is in place during the first day after admission. In these instances, however, the hard stop remains in effect, thus forcing reconciliation to occur the next time the patient's EMR is opened (typically shortly after the first 24 hours has passed). This scenario occurs most often when a patient has been admitted early in the morning. For example, for a patient admitted at 8 a.m., the hard stop goes into effect at 2 a.m. the following morning. Unless someone opens the patient's EMR during overnight hours, reconciliation may not occur until after 8 a.m., which is no longer within the first 24 hours of admission.

More Information

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Contact the Innovator

Adam S. Evans, MD, MBA
New York Presbyterian Hospital
435 E 70th St., Apt 14 I
New York, NY 10021
(973) 568-3317
E-mail: asevans3@gmail.com

Peter Fleischut, MD
Assistant Professor of Anesthesiology
Department of Anesthesiology
Weill Cornell Medical College
Deputy Quality and Patient Safety Officer
New York-Presbyterian Hospital
525 East 68th Street, Box 124, Office M-308
New York, NY 10065
(212) 746-2678
E-mail: pmf9003@med.cornell.edu

Innovator Disclosures

Dr. Fleischut reported having no financial interests or business/professional affiliations relevant to the work described in this profile.

Dr. Evans has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Evans AS, Lazar EJ, Tiase VL, et al. The role of housestaff in implementing medication reconciliation on admission at an academic medical center. Am J Med Qual. 2010 May 25. [Epub ahead of print] [PubMed]

Bails D, Clayton K, Roy K, et al. Implementing online medication reconciliation at a large academic medical center. Jt Comm J Qual Patient Saf. 2008;34:499-507. [PubMed]

Footnotes

1 Poon E. Medication reconciliation: whose job is it? Morbidity and Mortality Rounds on the Web. AHRQ. September 2007. Available at: http://www.webmm.ahrq.gov/case.aspx?caseID=158
2 Thompson K. Medication reconciliation: challenges and opportunities. Am J Health Syst Pharm. 2007;64:1912. [PubMed]
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: March 16, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: May 07, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: April 01, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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