1. Web-based Application for Transfer-Discharge Medication Reconciliation Nick Honcharik, Pharm. D. Regional Pharmacy Manager WRHA

2. Case – MedRec at discharge Mrs DE, 83 presented to ER with nausea, weakness and a history of “passing out’ at home PMH: HTN, Diabetes, AFib In ER significant lab tests: – Glucose 2.8 Med Hx: Glyburide 5mg bid, Metformin 500mg bid, Warfarin 4mg daily, Hydrochlorothiazide 25mg daily, Metoprolol 25mg bid. Recent discharge from hospital with similar symptoms.

3. Case review Glyburide discontinued last admission, but patient told to resume home medications on discharge. The previous admitting physician had intended to discontinue Glyburide but had not stated this explicitly. Outcome: The repeat admission could have been prevented and potential harm avoided.

4. Transfer / Discharge process Many WRHA sites had started and moved toward sustaining admission MedRec Eagerness to start transfer/discharge process Development of a Pharmacy Information System (Cerner/Centricity) generated medication list for discharge MedRec

6. Electronic Discharge Form Easy to read Avoids transcription errors Allows prescriber to select the medications that should continue (or change, stop) at the next level of care. Becomes a valid prescription Community pharmacies love it! Copy remains in the chart Closes the loop of communication between patient, community pharmacies, primary care physician

7. Transfer / Discharge process Unable to spread electronic discharge form due to inaccessibility of form by non-pharmacy personnel Trial of manual discharge MedRec - Failed Some areas/sites do not want to start admission process without having the discharge process Discharge MedRec may promote the importance of admission MedRec and potentially increase compliance Briefing note to senior management - pharmacy resources to print discharge MedRec form

8. Web based MedRec application In cooperation with Manitoba e-Health, developed web-based application Provides an electronic discharge form for medication reconciliation Populates medication information from pharmacy computer system into Discharge MedRec form Access given to designated staff members on the unit for generating the form on demand

13. FAX COVER SHEET Confidential Facsimile section to be completed when faxing Rx Physician certification as per legislation General instructions to Pharmacist

14. Demographics print on the form Scheduled medications checked off as “Continue”,“Change” or “Discontinue” Quantity DEFAULTS to 30 days. Space available to write in different quantity, along with number of refills.

18. Pre-admission medications to be restarted or discontinued are indicated in this section Changes to current medication (dose/route/frequency) written in this section, along with new medication starts

19. FOOTER - DISCHARGE Medication Reconciliation/Prescription Physician prints and signs EACH page along with date/time & licence # Date and time prescription printed Total number of pages provided

20. Pediatric Discharge MedRec Rx

21. DATA ENTRY function of application

23. Physician Survey HSC Pilot Unit N = 5 Question Strongly Disagree DisagreeNeutralAgreeStrongly Agree Form easy to access 2111 Accurate med list 122 Easy to use 1112 Helpful in the Discharge process 212 Saved Time compared to traditional process 32

24. HSC Pilot Unit Discharge Audit June 21-27, 2010 14 charts audited –79% (11/14) had a discharge MedRec form 10/11 with a discharge MedRec had an Admission MedRec 10/11 had a “prn” med continue 8/11 had the last page available –5/8 completed “pre-admission” section

25. HSC Pilot Unit Discharge Audit June 21-27, 2010 Done Well Form was reviewed and signed the same day generated All decision boxes checked off – i.e. no orders missed (scheduled or PRN) Each page was stamped with “COPY” Improvement Needed Ensuring ALL pages are in the chart Completion of “pre-admission” section Filling of the form in the orders section of the chart

27. MedRec Example Admission to Discharge

28. EXAMPLE OF COMPLETED MEDICATION HISTORY

29. Completed MedRec Discharge Form

31. PRN medications are reconciled Each page is invalidated