Health Care's Most Wired

Leadership, Culture and Medication Safety

cover About 1.5 million Americans are hurt each year by medication errors, according to the Institute of Medicine. The cost of treating these errors in hospitals alone conservatively accounts for $3.5 billion a year. The toll on patient safety and the bottom line is significant, particularly because these errors are in large part avoidable. To explore how hospitals are harnessing technology to improve medication safety, Health Forum convened a panel of hospital executives and industry experts Oct. 25, 2007, in Chicago. The closed-door dialogue focused on the development of effective systems to ensure patient safety and how organizations can build redundancy to prevent harm to patients. Health Forum would like to thank all of the participants for their open and candid discussion, as well as Accenture, Intel, McKesson Corp. and Siemens for sponsoring this event.

MODERATOR (Alden Solovy, Health Forum): How are we doing as an industry when it comes to medication safety? What’s your assessment of where the industry is in terms of applying information technology to the improvement of medication safety?

ANGELA NIChOLAS, M.D. (Susquehanna Health System): We’re early in the evolution of the technology products. The products available today are good, but they could be better. One of the barriers to adoption is expense. It’s the same story we hear with every technology that we try to adopt in hospitals. A lot of hospitals won’t have the opportunity to purchase these technologies until the price comes down. The more users we get, the better the systems are going to be.

ROSE ANN LAURETO (University of Illinois at Chicago Medical Center): I’m not sure the situation would be better with more sophisticated technology. Workflow issues are rampant. For example, with medication reconciliation, there’s a debate over whose responsibility it is to collect the information. We’ve had the ability to have a unified problem list of medications in our organization since 2000, but we haven’t adopted a standardized problem list in our environment. The problems have little to do with the technology.

MARY BETH NAVARRA-SIRIO, R.N. (McKesson Corp.): I agree, but I don’t necessarily think it’s an operational problem. It’s a cultural problem. Look at how we’re educated as health care professionals. We don’t have a team approach to education; we’re trained in silos. We have to fundamentally change the culture of health care. That will require transformational leadership. We need people, processes and technology to change if we’re going to make the quantum leap to safety.

The organizations that have begun to successfully change their culture are those with involved CEOs who go out to the nursing units and talk to the nurses. They ask the nurses directly how they are doing and ask what can be done to make things better. They help empower the nurses. As Rose Ann said, the technology is there. But a lot of the technology out there isn’t even getting used, and that’s because we need to change the culture, we need to change processes, and we need leadership to step in and make the transformation.

MODERATOR: Bruce, you’re nodding vigorously.

BRUCE SMITH (Advocate Health Care): One of the things we’re beginning to see is that the technology is disruptive. It can make employees uncomfortable and angry. But that can be a positive thing because it forces people to change their behavior patterns. I was at a focus group for physicians recently and some of their anger was directed at technology. But when we push back, we learn that the technology has nothing to do with it. They are upset that they are being forced to change and because the data shows that they aren’t doing as well as they thought they were. They are out of their comfort zone.

We are at the first step, which is getting people out of their comfort zone and doing things differently. The question is, where are we going to end up?

MODERATOR: Tanya, you had the opportunity to work on developing a hospital from scratch, and yet I get a sense that some of the same issues exist.

TANYA TOWNSEND (Saint Clare’s Hospital): Absolutely. We knew that this was going to be a cultural, transformational change. We hired a lot of our leaders six months to a year ahead of time to start putting the processes in place. All of our processes, from CPOE to medication reconciliation, were built by multidisciplinary committees. Everyone was energized about being able to do things differently: new people, new building, new systems —everything was new. It wasn’t a replacement facility. People had to come in with an open mind. Our hospital implementation was a big success.

However, we still run into the exact same challenges faced by long-standing hospitals. For many of our processes, there’s uncertainty over who is responsible for certain jobs. Even though this was the process that we created, there is a lot of pushback.

ROB CHRISTIANSEN (Siemens): From a cultural standpoint, it’s much easier to get nurses to change their work habits. It’s easier to get them to bar code at the point of care. It’s not as easy to get physicians to change. Physicians have a lot of power within health care organizations. They push back, and they don’t want to enter orders online. It’s really that simple. We’re seeing this across the board. Computerized provider order entry systems have been around for years. But right now, only 5 percent to 10 percent of hospitals in the United States are using CPOE. About 20 percent of U.S. hospitals, including the Veterans Affairs medical centers, are bar coding at the point of care. We have a long way to go before CPOE adoption is more pervasive. In order to get there, hospitals have to address the change issues.

TOWNSEND: That brings up the issue of incentives. Physicians need incentives to facilitate adoption.

PAT PERRY (Intel): Yes, incentives will help change their behavior.

NICHOLAS: My organization provides incentives to employees based on financial productivity, patient safety goals and customer satisfaction. We all have a financial stake in the success of our hospital system. When we make decisions, we think about the impact on the organization’s financial health and patient safety. It works. More importantly, the employees see the value in what they are doing and they want to continue to succeed.

SMITH: I’m a strong advocate of incentives. If physicians are willing to use CPOE, I’m willing to give them a PC. If you look at the cost of a PC versus the value of CPOE, there’s no comparison.

Still, we have people who are reluctant to get involved in these incentive programs. We’re working on a presentation for our board regarding incentives. We calculated the projected cost if 40 percent of our orders need follow-up from between one to three clinicians. We just did some simple multiplication based on 15 minutes of nursing time spent clarifying paper orders; the end value is $15 million in savings based on nursing time.

When I showed the report to the hospital presidents, they expressed some concerns about how the board would interpret these numbers. But we’re going to go ahead with it. It provides an economic reason, on top of a compelling patient safety reason, to push CPOE adoption. By providing PCs as an incentive for CPOE adoption, we can achieve a great deal of savings. In fairness to the physicians, we are asking them to do things differently, and sometimes giving them a reward is not a bad trade-off.

NICHOLAS: When we reduce physicians’ productivity, we’re hitting them in their pocketbook. We often forget about that. The only way physicians make money is by seeing patients, and if it takes five minutes more per patient over a week, it adds up. That’s not fair to them, and we keep asking them to do more and more. They are burdened with all the things that we are asking them to do, such as medication reconciliation. And they don’t get reimbursed for it. We need to be sensitive to that.

SMITH: I hear comments from physicians who feel we’re making them do clerical work. I have to remind them that we’re not asking them to order napkins and supplies for the floor. We’re asking them to place a sophisticated medical order. That’s not a clerical task. That’s why they went to medical school. Other people don’t have the skills to do it. We have to change their perception about the tasks.

NICHOLAS: That’s an important message to get across. For example, at our hospital, physicians will often write orders for tests that we don’t even do. The unit clerk then decides what test the patient will receive. For example, we have six stress tests in our hospital. Physicians still write orders for stress tests that we did years ago but no longer do. When they hear that the clerk is rewriting the orders, the physicians know they should be the ones making these decisions. With CPOE, the physicians can order only the tests that we offer. That’s another incentive.

LAURETO: In some organizations, it will take mandates from leadership to get physicians to use CPOE. Too often, we practice defensive medicine rather than offensive medicine. We wait for the Joint Commission or the Centers for Medicare & Medicaid Services to tell us what to do. We don’t want to be provocative and tell our physicians how to do things.

The whole process is very confusing. There is a lot of pushback, largely due to time constraints. It’s about productivity. But implementing technologies such as CPOE and bar coding is what’s best for the patient. That should drive the incentive.

NICHOLAS: I agree 100 percent. We have to create a balance, though. In my outpatient practice, we do medication reconciliation for every patient. No exceptions. But I can understand that orthopedic surgeons don’t feel that it’s their responsibility. They might not know what all of the different medications are, so what’s the point of writing them down and dictating them in their notes?

BRIAN SHEA (Accenture): Patient safety awareness has grown tremendously over the past 10 years. And the technology is developing at such a fast pace. I’ve never seen development cycles in this industry as fast as they are today. Changing culture is challenging. The implementation of new technologies requires new processes.

We’re drawing light to issues that we could have or should have improved a long time ago. That’s hard for organizations because they now have a quality journey on top of their IT journey. There are still organizations out there accustomed to the program-of-the-month approach. They focus on particular areas because they are being told to do so. When the next issue comes up, they move on. That’s hindering our ability to change culture.

MODERATOR: Mary Beth brought up the issue of leadership. How can health care leaders make sure the organization understands that medication safety and quality are priorities? What do we need from leadership to make this journey a success?

PERRY: What Mary Beth said resonates with me. I come from Silicon Valley, where health care is generally a high-tech environment but still extremely hierarchical. What the doctor says or does should not be questioned. Part of the solution is creating a culture of empowerment, and I have a good example of how technology can assist with this.

We conducted a mobile clinical assistant trial in the United Kingdom that automated the ordering system for phlebotomists. The old system was paperbased. The phlebotomists received their orders in the morning and crossed them off as the day progressed. Those orders might change, and often the phlebotomists were conducting unnecessary blood draws. With the automated system, they were notified of changes immediately. If a doctor came up and asked why a test wasn’t taken, they could show the cancellation order. It empowered them to go up against a physician.

This shows that we won’t change behavior simply by providing financial rewards. That will only go so far. Caregivers need to feel as though they make a difference. They need to be heard.

NICHOLAS: I don’t want to come across as criticizing nurses, but the nursing culture plays a role as well. Nurses, too, can be resistant to change. In some organizations, they haven’t had any exposure to technology. So technology adoption will be a major change, and it’s frustrating to learn to do something differently. They don’t want to do things differently. It’s hard to change that culture. Everything gets perceived as an IT project, but medication safety is really a nursing project. IT simply provides the tools. Nursing has to take ownership. They’re taking care of patients. We really struggle with this whole issue.

NAVARRA-SIRIO: The focus has to be patient-centered care. With that focus, things do begin to change. But right now, we tend as clinicians or other professionals to think about how we do our own work. That’s not the correct approach. We should ask how we can provide the best care for the patient. And if that means we have to change what we’re doing, then we have to change what we’re doing.

The places I’ve seen that have been the most successful on the patient safety journey are those where the senior executive team has said patient safety is job one.

The AHA-McKesson Quest for Quality Prize each year recognizes organizations that have successfully implemented the six Institute of Medicine quality aims. Last year, during a site visit, we met with the board chair at one of the organizations that applied. He was a young guy, a banker from the community. He said that he made patient safety the first report on the board’s agenda. He did that on purpose because it emphasized the fact that patient safety is the organization’s main mission. Finance and hospital management are presented in the second report. He said that sent a huge message to the organization about patient safety.

Decisions that are made reflect that priority. The message has to reach everybody in the organization. And then the management behavior has to support it. For example, in a well-known story at Children’s Hospitals and Clinics of Minnesota, a pediatric nurse in a cardiac OR stopped a cardiac surgery because she felt something was wrong. That’s a bold move, especially when you consider the revenue and the throughput implications. The surgeon called the chief medical officer and the CEO, yelling, but they stood behind the nurse for voicing her concerns.

That’s an example of how leaders have to walk the walk instead of just talking the talk. That will change behavior throughout the organization.

SMITH: Safety is moving to the top of the agenda at most organizations. At my organization, it is the No. 1 item on the board’s agenda. It’s up to the leadership to keep it there. That’s the most important thing they can do. It’s still tough, however, to secure leadership involvement in technology projects.

I get the sense that some would rather build buildings than implement processes of change. Often technology projects take a backseat to building projects when it comes to budget, time and attention. It’s easy to get a hospital president to attend a meeting about a building project. It’s harder to get him to come to a technology meeting. There’s still a sense that it’s a technology project that should be handled by the IT department.

LAURETO: UIC is an academic medical center. The university created a safety institute that works with the various colleges. The institute puts patient care teams together so the students can see how they will react together in a real patient-care setting. One of the first examples addressed hand washing and how a non-physician caregiver would confront a physician for not washing his hands. It provided an opportunity for everyone on the care team to feel comfortable with challenging a physician because he hadn’t washed his hands, and hopefully that will carry over into the true work setting. This caught our CEO’s attention, and now safety is talked about all of the time from a cultural perspective.

We focus on how we can get to feel safe about communicating concerns without ramifications. If we get something on a leader’s radar screen, we can resolve the issue. Safety is at the top of our agenda at this point.

TOWNSEND: Our leadership was a big part of the success of the opening of our hospital. All of our IT projects are actually run by clinical leaders, and the team includes a business manager from that area. IT is a partner at the table. The success of the project is on their shoulders. Of course, as we started to plan for our hospital, we had to plan for the IT systems we would use. We started identifying our multidisciplinary teams right away. Many members did come reluctantly, assuming it was an IT project. We showed them how the system worked. We asked how we could successfully implement the technology with their workflow. Some people responded with accusations that IT was driving the bus and that it shouldn’t be that way. So that’s when we recognized that we needed the sponsors and business managers driving this. Our CMO drives the process. We use a project management methodology to identify the appropriate managers responsible for a project.

Another critical part of our success was process-mapping and building that into the workflows and the training and education plans. I would just reiterate that it starts with leadership at the top. They have to stay strong so the squeaky wheel doesn’t make them change their mind. It’s important to demonstrate that leadership will hold people accountable as well.

SHEA: Sometimes leaders forget that part of being a leader is being visible in the effort. At the start of our projects, we ask the CEO to make a few comments to the caregivers. We ask them to thank the staff for their participation and explain the importance of the project. If the caregivers see that the CEO is involved, they will begin to see the project’s importance.

NICHOLAS: What about the chief financial officer? The CFO is the guy holding the purse strings. We found that the more that we can explain to our CFO in lay terms what’s happening and where things are going and making him part of the solution, we are more successful with getting his support. It’s the CEO and the CFO who really need to be the ones out there championing projects to the board.

MODERATOR: So what is the CFO’s role? How can the CFO influence the organization’s culture around patient safety?

PERRY: The CEO and CFO work closely together. When you have the business case in place and the business value metrics carefully laid out, it will help get the CFO behind you. But more importantly, the CFO will influence what the CEO feels is important.

LAURETO: Our CFO has been very supportive. We make decisions as a group. Our CFO ensures that the capital projects are funded at the rate that the team views as necessary. In some cases, that means moving money out of some beloved building and remodeling projects. We are implementing projects to enhance the functionality of the ICU and OR because the CFO helped us shift some money on the basis of the clinical need. The CFO role is very important in that he helps us balance our checkbook and direct the money to where it needs to be spent. They have business savvy, and they have to understand where the priorities of the organization are and how to fund them.

TOWNSEND: It’s very likely that implementing medication reconciliation will adversely affect productivity. It involves complex processes. Some people might gain efficiencies, while others might become less efficient. Working with the CFO can us help understand what the full-time employee requirements and the productivity might look like as well as what will be gained from a patient standpoint.

MODERATOR: Let’s talk about CPOE and medication matching. In the Most Wired Survey and Benchmarking Study, we ask for the percentage of medications ordered electronically by physicians, and we ask for the percentage of medications administered that are electronically matched to the patient, the provider, the order and drug at the bedside. Only 24 of the approximately 580 organizations that took the 2007 survey said they do both, assuming 60 percent usage. One hundred and nineteen organizations said they have full adoption for medication matching at the bedside, and 57 have full adoption of order entry.

Let’s talk about the state of the industry. Is this surprising to you? What are the barriers here?

SHEA: Well, vendors are still putting together their solutions for bar coding at the point of care. Some are farther ahead than others. Some are very good; some of them are still trying to integrate. For organizations that are adopting bar coding at the point of care, it’s not just about the technology. The pharmacy has to make sure they can get the products coded. It’s one of the toughest things to adopt right now in health care.

SMITH: There are a lot of steps that hospitals need to go through before they can accomplish full adoption of order entry and bar coding. There’s still some difficulty on the technical side, although that’s been solved to some degree. Achieving full adoption of bar coding would require multiple-vendor solutions, and that is complicated.

We’ve talked about bar coding at the bedside, and we’re still having issues. Some of our nurses bar code at the bedside, but we have many that don’t. We’re just not ready yet. We’ve realized that the nurses are ready but the technology isn’t as smooth as we need it to be. We don’t have all the pieces in place yet to make it happen. I believe that’s happening throughout the industry.

NAVARRA-SIRIO: We have a bar-coding product that’s been available for a long time, and we have hundreds of customers that are scanning meds at the bedside. One of the keys to success is something that Brian alluded to earlier, and that’s re-engineering processes on the back end. If you want to get nurses to scan meds at the bedside, you have to have all products prepackaged and readily available when the nurse needs it.

I’ve seen systems where some items are bar coded and other things are not. In those instances, the nurses don’t value the technology. Organizations have to figure out how to get a bar code that’s machine-readable and scannable on everything that is sent to the nurse in unit dose levels. That takes the pharmacy really thinking about its drug distribution models. There is technology that can help with this process. Organizations have to think about that piece first. It’s helpful to look at organizations that are doing it successfully. We have 135 million doses a year being scanned with McKesson systems, so there’s a lot of scanning going on out there.

LAURETO: We ran a bedside bar-coding pilot last year. It was a complicated project. The technology wasn’t where we needed it to be, and we encountered some pushback because of nursing workflow issues. This is something we want and need to do, but we are going to wait. We’re focusing on medication reconciliation because we want to wait until the bar-coding technology catches up and until we have enough energy to address all aspects of this project.

It’s a big initiative that requires lots of changes everywhere. Take staff badges, for example. The badge has to contain some type of identifier. The patient armbands need an identifier. The drugs must be coded. Everything has to be in place for this to work.

TOWNSEND: I agree with what has been said so far. The barriers include a resistance to workflow changes and the actual technologies, among other things. Currently, bar coding doesn’t have an external mandate. The reimbursement agencies are starting to catch on to that. Pretty soon, we won’t get reimbursement without some sort of scanning technology in place. I believe that’s right around the corner.

CHRISTIANSEN: Many organizations are starting with bar coding because it’s an extension of the pharmacy. The numbers are much higher for bar coding at the point of care than for CPOE, although CPOE has been around longer. Many organizations start with bar coding because they feel it will help them achieve the greatest bang for their buck in terms of cost savings and improved patient safety. After that’s accomplished, they start working on the physicians in preparation for CPOE and creating a closed-loop medication cycle. It takes longer to get the closed-loop process in place. We have about 15 hospital systems practicing closed-loop medication management right now and many headed in that direction.

SHEA: Even organizations that have fully implemented bar coding and e-prescribing are still seeing workarounds. The short battery life makes the use of laptops and carts challenging. Some organizations have stored the carts in the hallway to keep them charged, and the nurses will scan the meds before going into the patient room. The Joint Commission cited one organization recently for storing the carts in the hall. They said it created a fire risk. There are unanticipated consequences when bringing new technology into an environment. When we stumble, we can create more risks. This is so important to get right.

SHEA: Are we going to talk about radio-frequency identification at some point? It’s worth considering. There are probably one or two hospitals out there that have figured out how to get RFID at the unit- of-use level for medications. Bar coding requires process change. That’s one of the hardest things. It requires equipment to be brought into a patient’s room and items to be scanned. RFID can create passive systems that can support much more. We’re hoping that RFID at some point will leap to the forefront in the next couple of years. In the interim, we’re focused solely on how to get bar coding to work.

MODERATOR: Is RFID a viable solution?

NAVARRA-SIRIO: The advantage of RFID over bar coding isn’t there yet. All it does is change the way an item is scanned. We are using RFID on a lot of things, but organizations have to weigh the cost and benefit against the alternatives. RFID may make sense for expensive items, such as a chemo bag that’s been mixed for a specific patient. I think the solution will be a combination of things.

PERRY: We did two big pilots in Europe with RFID for blood transfusions. The RFID tag was on the bracelet as well as the bag. One of the hospitals was a 1,100-bed hospital in Milan, Italy, and the other was in Germany. The return on investment was such in both cases that it was rolled out to the entire hospital.

NICHOLAS: What problems were they trying to solve? Were they losing the bags? Was the blood expiring?

PERRY: It was a combination of things. They had some errors, where the wrong type of blood was given to the wrong patient. I can’t remember the numbers, exactly. But it was large enough for them to get involved with us and some other industry partners to develop a solution.

CHRISTIANSEN: From a medication perspective, I don’t think the ROI exists yet for getting the economy of scale on producing RFID tags to put on all the medications. There are other issues, too. From a common-sense perspective, there’s a proximity issue. If a nurse has a cupful of meds with RFID tags, they could scan them, but are they verifying them all at that time? What if one of the medications is due later? There are many things to consider.

SHEA: Cost is still a barrier for RFID. In the hospital, a dose of Tylenol costs you almost nothing. Placing an RFID tag on the dose would cost 10 cents. That can be prohibitive. Once the cost comes down, we will see greater usage, particularly in the area of medication safety. At this point, it’s still early.

MODERATOR: Many hospitals took a wait-and-see approach on bar coding. Are they now waiting for RFID?

LAURETO: RFID has a lot of promise. But I need to be able to bring a quantifiable ROI to the table. I can’t find that with RFID yet. We can hire people to find our wheelchairs and pumps 24 hours a day, seven days a week, at a cheaper price than it would cost to wire the organization with RFID readers.

NAVARRA-SIRIO: One of our customers was having trouble finding IV pumps. They were about to buy 100 additional pumps. We placed RFID tags on their current pumps, and they’ve been able keep track of everything and make sure the item receives scheduled maintenance. They haven’t needed to purchase any new pumps.

LAURETO: I’m not disagreeing with you. I pitched that at my organization, and the thought was that it would be cheaper to hire some students to run around and look for lost items. But I want RFID.

MODERATOR: So the general consensus is that bar coding is the way to go?

NAVARRA-SIRIO: Our customers are seeing some financial returns with bar coding. We have a customer in Ohio that got a 15 percent premium reduction in its reinsurance policy because they scan bar codes at the bedside. As these types of incentives become more readily available, that will help hospitals fund some of these projects.

SHEA: One of the remaining problems is the lack of standards for bar codes. Some of the items we receive are labeled with the National Drug Code number; others are labeled with a catalog number. Bar coding is proven to improve safety and quality. However, it would be difficult to mandate use of bar coding without standards in place. We need to push for uniform standards. It needs to be done soon.

MODERATOR: Let’s dig into medication reconciliation. I thought this was a fairly straightforward process, but I’m beginning to sense otherwise. What does it take to do medication reconciliation?

NAVARRA-SIRIO: The Joint Commission regulation is high level. It says that medications need to be reconciled at every point of change.

LAURETO: There are multiple entry points into hospitals, and patients often don’t know enough about what they are taking to share the right information.

One of the biggest issues is that of responsibility. It’s not the responsibility of one person. It will impact a number of people.

There has been a great deal of discussion about who compiles the list of medications and how it will affect their workflow. The physicians know they’re accountable in the end but are very resistant to the process and the time.

SHEA: The process is a mess. It’s hitting us in an area where we are weak.

NICHOLAS: It’s difficult, even with the benefit of technology. In my practice, I have an electronic medical record, and we conduct medication reconciliation for every patient. It’s so complicated that it can never be right.

We are trying to make the process easier. We’re piloting a process right now with the pharmacy. The pharmacist prints out a patient profile, and the physicians circle the medications that they would like to renew. The response has been positive. The order gets faxed to the pharmacy, and the pharmacy updates the profile.

CHRISTIANSEN: Ultimately the process is physician-driven. They are responsible for ordering the medications. The nurse or the unit secretary should interview the patient upon admission, or maybe it’s the physician if it’s in the ED. There are systems that can bring outpatient prescription data into the hospital setting. If patients have been to multiple pharmacies, the clinicians can see all of their prescriptions at the insurance-carrier level.

There’s no one solution. There are multiple sources of this data, and it ultimately comes from the patients because they change their own prescriptions. They might not take one of their medications; they might have never filled the prescription. And as the patient transfers through the different levels of care, there are different processes in place. It’s very complex, and everybody does it a little bit differently.

We find that it’s physician-driven, and at some large academic medical centers the pharmacists get involved, too. Typically, however, pharmacists are not available 24/7 to go reconcile meds for every single patient. Nurses conduct a medical assessment up front during a patient visit. That’s a good opportunity to collect medication information. So it’s mainly nurses and physicians involved in the process.

NICHOLAS: I understand the goal of medication reconciliation, but it doesn’t always make sense. When a patient comes to the hospital with a stroke, the medicines from the outpatient environment can be somewhat irrelevant because the formulary is different in the hospital, the dosages are different and so is the method of delivery. Yes, it’s important to know that the patient is on a lipid medicine, but the hospital might not carry the same medication. At discharge, we have to know what medications the patient is taking at home, and the patient needs to know what they’re on at the hospital. That has to be reconciled before they go home.

NAVARRA-SIRIO: So how do you reconcile at discharge if you didn’t do medication reconciliation at admission? I’m surprised.

LAURETO: Someone has to gather that information somewhere during the process. For the most part, our physicians believe the nurses can do this at any point during the patient’s stay. I’m not saying that’s right or wrong. But that’s the general consensus in the conversations that I’ve been in.

NAVARRA-SIRIO: Well, it’s hard to say whether the medications the patients are taking at home matter or not. If the patient’s on insulin or Coumadin, it matters. It matters if they’ve taken these medications in the morning and they show up in the ED in the afternoon.

NICHOLAS: That’s true, but for inpatients there is a slight difference. The patient may be taking Lantus to control their blood sugar. In the hospital, we might place them on a sliding dosage scale because it’s cheaper.

It’s important to know, but from a technical perspective, it doesn’t always matter. That’s my personal opinion. It doesn’t matter as much as what goes on from admission to discharge. Discharge is the most important part of the medication reconciliation process because it’s important for things to be in order when the patient goes home.

TOWNSEND: We have a single medication list across the continuum; that has helped us with this process. We’re the predominant provider in the area. We do get patients from outside of our system; that’s more challenging.

Medication reconciliation has an impact on physicians in terms of productivity. But we’ve seen gains in pharmacy efficiencies. Through CPOE and medication reconciliation, we’ve been able to decentralize our pharmacists. They spend more time on the units educating the clinicians and assisting with CPOE and reconciliation. That’s a very positive outcome for us.

NICHOLAS: That’s a great model. Having the pharmacists assist with medication reconciliation is the right thing to do. The pharmacist has a wealth of knowledge about drug interactions. To have a pharmacist available on the orthopedic floor 24/7 would be fabulous.

SMITH: In the areas where we are doing medication reconciliation, the relationship between physicians and the pharmacy is better than it is in other areas. It’s because the pharmacists are more involved. There seems to be more of a teamwork approach.

LAURETO: I’m not a clinician, but I’ve been relatively involved in this process. I attended a couple of sessions sponsored by the Joint Commission that showed best practices. One of the things I brought back was the idea to increase the number of pharmacists and pharmaceutical technologists and strategically place them in areas where we might have resistance to medication reconciliation. We had a lengthy discussion on the topic, and the director of pharmacy was supportive of the idea from a workflow perspective.

In the end, however, the CMO, who the pharmacy reports to, did not want to change the model. We have a lot of pharmacists on the staff. The CMO said that medication reconciliation is ultimately the physician’s responsibility, and that’s the workflow he wanted to support. I don’t think it’s such a bad idea to help augment the process by bolstering the role of the pharmacists in some areas.

MODERATOR: CPOE impacts physician workflow. Medication reconciliation impacts nursing workflow. It seems that these medication safety practices are in turmoil at this point. Is that an overstatement?

SMITH: I wouldn’t say that it’s in turmoil. That would mean that patients were completely unsafe before. That implication would offend some of our doctors. This is an emotional issue for them because they believe they’ve been providing safe care to their patients.

SHEA: Medication reconciliation isn’t something that we’ve done terribly well, in my opinion. That’s one of the reasons that we are struggling with it so much now. It would be nice if automation would fix these problems. But there are process issues involved. We can’t agree among ourselves who is responsible for medication reconciliation. Technology is not going to be the 100 percent solution for this. We will need to fix the process as well.

NAVARRA-SIRIO: Some organizations approached medication as a regulatory issue, but once they got involved, they saw that it’s a safety issue. They went from wringing their hands trying to create a checklist to show to the Joint Commission to trying to develop comprehensive programs.

Organizations need to take a step back and use this as an opportunity to change the workflow process. Some organizations are doing this rather well.

It may also help to look at the critical points. Discharge, for example, is an important part. There’s a lot of work to be done. But we’re making progress by acknowledging that we can do better and trying to figure out how.

MODERATOR: What’s the measure of success for medication reconciliation?

CHRISTIANSEN: The measure of success would be a decrease in adverse drug events. That’s what this is all about. It all boils down to safety. The end result will be a decrease in adverse drug events.

TOWNSEND: Compliance can also be a measure of success. The organization needs to do what it says it’s doing. To be successful, medication reconciliation can’t solely be the hospital’s responsibility. Outpatient providers should be doing this as well. Everybody has to play their part.

Panelists

Rob Christiansen Global Marketing and Business Manager, Pharmacy Solutions Siemens Malvern, Pa.	Pat Perry Vice President, Digital Health Group, and General Manager, Health Information Technology Intel Santa Clara, Calif.
Rose Ann Laureto CIO University of Illinois at Chicago Medical Center	Brian Shea Senior Manager U.S. Health Providers Practice Accenture Boston
Mary Beth Navarra-Sirio, R.N. Vice President and Patient Safety Officer McKesson Provider Technologies Cranberry Township, Pa.	Bruce Smith Senior Vice President and CIO Advocate Health Care Oak Brook, Ill.
Angela Nicholas, M.D. Former Vice President, Physician Resources/CMIO Susquehanna Health System Williamsport, Pa.	Tanya Townsend Director, Information Technology Saint Clare’s Hospital Weston, Wis.
Moderator Alden Solovy Associate Publisher and Executive Editor Health Forum Chicago