1. Medication Safety Ambulatory Medication Safety Effie Brickman, Director Ambulatory Medication Safety ebrickman@macoalition.org www.macoalition.org

2. Refer to this quickly Other Area Projects n Professional Organizations Currently Testing Medication Lists: n Two other Massachusetts ambulatory settings are completing testing n All ambulatory hospital settings required by JCAHO to reconcile as of January 2006. n Lessons Learned from Other Projects n Coalition will incorporate lessons learned and helpful strategies from these projects upon completion

3. One Hospital Ambulatory Model Testing n 13 pilot units, July-Oct 2005 n 7 with 1-2 providers, 6 with multiple n Teaming with RN managers, operations leaders, clinic assistants n Advance email to program leaders and clinicians n On site, in-service support for MDs, NPs

4. One Hospital Ambulatory Model Testing n Return rate varied 20-80% n Busy days are hard n No show vs. not printed vs. not given vs. not completed vs. pitched out vs. lost n Generally positive response from patients, staff, providers n Lots of practical pitfalls and lessons about work flow, technology

5. One Hospital Ambulatory Model Testing (cont’d) n Collecting data, but not entering it, may pose a liability risk to the hospital n Failure to update lists may reflect poorly on our care and be disrespectful to patients n Data entry is a burden for busy clinicians n Frequent requests may be annoying to patients and unnecessary work for staff

6. One Hospital Ambulatory Model Testing (cont’d) n Clinician survey n N=12/46 n 3:1 favorable to neutral responses n Comments “It’s a very helpful thing.” “Saved MD time; Used patient time well and caught mistakes.” “We need a system to do this automatically with less provider involvement due to time constraints.” “I found it helpful… to update the LMR. It probably saved time.” “I update the med list for allergies at every visit.”

7. One Hospital Ambulatory Model Testing (cont’d) n Programmatic commitments n Agreement to limit frequency of queries n Proposal to automate queries n Est’d 3-12 month development n Resources identified for half-time RPh n Ability to enter all changes n House-wide implementation Nov. 2005 n Evaluation

8. One Hospital Ambulatory Model Testing (cont’d) n Method n Usual care patients n First 2 per provider, all units, Nov ’05–Jan ’06 n Updated med sheets collected n Screened for safety n Charts reviewed 2 wks later, forms then to MD n Intervention group included all med rec patients, same units, same dates

9. One Hospital Ambulatory Model Testing Reconciled Med Lists n Med List Updates n Pilot Intervention 90% (38 out of 42 med lists updated) n Usual Care 2% (1 out of 47 med lists updated) n Med List Changes n Pilot Intervention 3.7; Accepted Changes 3.6 n Usual Care 4.6; Accepted Changes 0.1

10. Coalition Practice Pilot Sites n Solicitation of physicians commenced July 2005 with letters and phone calls to select MA providers n Cardiologists and Rheumatologists n Health Centers n Internists n Obstetrics/Gynecology n Hospital Professional Organizations

11. Practice Pilot Sites n Pilot site agreements reached with: n Internist (central MA) n Obstetrician/Gynecologist (metro Boston) n Family Practitioner (northeast MA) n Health Center – (central MA)

12. Interventions n Patients to carry a medication list to each provider visit n Promote improved physician-patient interactions, especially relative to understanding medication regimen, compliance issues, danger signs/side effects, potential interactions n Physician to reconcile medications at each visit

13. Testing Status n Individual Practitioners n Between 90% complete with testing medication list and reconciling process n Health Center n Initiated testing early January 2006 n Withdrew from testing February 2006 n Cited paper process cumbersome with EMR in place

14. Testing Tool - Patient n Patient Testing Included: n Notification to bring medications or list n Form simple to complete and carry n Form helpful to keep track of medications, dosages, reactions, etc. n Patient understood their medications/purpose n Process of reviewing medications with physician helpful

15. Testing Tool - Physician n Physician Testing Included : n Form incorporated all patient specific information n Time available to review medications with patient n Form helpful to keep track of medications, dosages, reactions, etc. n Inappropriate or conflicting medications found n Medications changed based on reconciling n Errors prevented n Changes recommended for the form and process

16. Preliminary Feedback- Patients n Patients didn’t always remember to bring their medications or list to the visit n Patients thought their physician had a list of all their medications and already knew the info n Patients thought their physician was already reconciling medications at each visit n Patients do not know or remember their discontinued medications

17. Preliminary Feedback -Patients (cont’d) n Patients on fewer medications felt the form was too big to carry while others felt the form was fine n All patients felt the form included important information n Most patients felt it was helpful to have their medications reviewed n Most ob/gyn patients did not know their vaccines or flu shots n Most ob/gyn patients tested did not think birth control pills and IUDs are medications

18. Preliminary Feedback - Physicians n Physicians felt the form included all important information n Physicians made updates or additions to medication list as result of reconciling n Reconciling process affected by patients not remembering their medications, physician, pharmacy, and emergency contact info

19. Preliminary Feedback – Physicians (cont’d) n Some inappropriate or conflicting medications were recorded when comparing the medication list to the patient record n Physicians did not recommend changing anything about the time they spent with the patient reviewing medications n Health Center physicians reported difficulty reviewing medications with patients requiring an interpreter (overly time consuming for this patient group)

20. Preliminary Feedback – Physicians (cont’d) n Health Center physicians withdraw from pilot citing cumbersome process for their setting and patient population n Physicians had mixed results on whether they thought the reconciling process was helpful but… n Updates made to patient’s file based on medication list review (allergies, meds, etc.) n Additions to medications were made n For older populations, lack of form completion hindered reconciling process

21. Timeline Develop Medication List PrototypeJul. 2005Completed Conduct Search for Pilot SitesAug. 2005Completed Establish Pilot Site Arrangements and Testing Agreements Sep. – Nov. 2005 Completed Commence Testing of Medication List with Physician Practices Nov.2005 – Jan. 2006 Completed Finalize Testing of Medication List with Physician Practices Obtain Provider and Consumer User Feedback Commence Planning for Educational Program Mar. 2006Completed

22. Timeline (cont’d) Commence work on the Development of a Strategy and Work Plan to Promote Implementation of Medication List through Outreach to Consumers/ Providers Apr. 2006Completed Disseminate Medication List/Sheet to Physicians and Ambulatory Setting Statewide May – June 2006 Completed

23. Next Steps n Revise Medication List Form and Reconciling Process Based On Testing Feedback n Obtain Lessons Learned from Other Ambulatory Initiatives and Incorporate n Develop Strategy for Statewide Dissemination of Medication List Form to Patients and Health Care Providers