When my mom’s primary care doctor recently told me that she had been assigned the duty of “medication reconciliation” before my mom was discharged from the hospital, I have to admit that I didn’t know what this meant. Before I looked up the term on the internet, I thought that mom’s primary care (or family) doctor was going to identify all the drugs my mom needed when she left the hospital, make sure there were no unsafe drug interactions between them, and identify any special concerns that needed to be monitored (like possible side effects, for example). My assumption about the reason for the medication reconciliation was naively based on the fact that I thought that medication reconciliation was purely done with the patient’s best interests in mind.
As I learned during my internet search, medication reconciliation is the process of (1) identifying a patient’s current drug list when they are admitted into a hospital, (2) making sure that all changes to it are applied to in-patient care, and (3) making sure the patient is discharged with an accurate up-to-date prescription drug list.
Medication Reconciliation when the current list is incomplete or wrong
Not all hospital admissions start with a complete and up-to-date drug list as was the case for my mom. My mom’s drug list before she went into the hospital was complete and up-to-date because she had kept her primary care doctor up-to-date on what she had been taking (including over-the-counter drugs and supplements). This allowed my mom’s primary care doctor to identify for the hospital my mom’s current medication list from day one in the hospial.
My mom was lucky to have such a patient-centered primary care doctor especially since the hospital’s Electronic Medical Record (EMR) system did not have the up-to-date drug list. My mom’s medical records from the cardiologist’s practice (which had been acquired by the hospital in the past year) apparently had not made it to the hospital’s EMR yet. Perhaps this was another reason my mom’s primary care doctor was given the task of medication reconciliation instead of the cardiologist who was filling in for her vacationing cardiologist.
When the new patient’s complete drug list is not available, hospital staff are often asked to piece together an accurate medication history using information from multiple and often imperfect sources, including the patient, family members and other patient advocates, the primary care doctor, medical specialists, outpatient medical records, hospital discharge summaries, and local pharmacies.
Medication Reconciliation within the hospital setting
The most up-to-date list of my mom’s prescription drug needs had to be available everywhere in the hospital where my mom was being treated or tested. While I knew that medication reconciliation at discharge was handled by my mom’s primary care doctor, I do not know how this process was managed at “all transition points within the hospital” (see the figure above).
When my mom was admitted into the hospital (shown as the figure on the left in the figure above), her current list of medications serves as the starting point for prescription drug changes that might need to be addressed during the hospital stay. Several members of the hospital’s professional staff have different responsibilities when it comes to making sure that my mom received the correct medications at the right times. The prescribing doctor (either her primary care doctor or the cardiologist) must identify a drug that is on the hospital formulary and include all necessary information for the prescription to be filled accurately by the hospital pharmacy. The hospital pharmacy, in turn, must fill the correct prescription and send it off to the correct patient. Additional hospital staff must get involved to make sure that the patient gets the right drugs at the right time.
When hospitals don’t have well defined medication reconciliation plans (e.g., identifying which healthcare professionals are responsible for medication reconciliation at each phases of the hospital patient’s care), then prescribing errors can occur. Before swallowing any oral drugs in the hospital, patients (if they can) should always ask what they are taking and why. It is a good idea to ask about intravenously administered drugs also. Given what I have seen (or heard from others), it is not surprising that about 60% of patients have been found to have taken one or more unnecessary drugs in the hospital setting. Most healthcare consumers are oblivious to the impact that poor medication reconciliation can have on their quality of care and final outcomes.
Medication Reconciliation at discharge
Medication reconciliation at the time of discharge is all about comparing my mom’s current list of medications against the new discharge orders and making sure my mom leaves the hospital with a complete list of what drugs she must take from now on (see the figure below).
Most of the changes to my mom’s drug list came from a cardiologist covering for my mom’s regular, vacationing cardiologist. Because the reason for my mom’s hospitalization was the deterioration of her heart function and the need to implant a pacemaker, I would have expected the cardiologist to take charge (and write her new prescriptions). Because the hospital has a financial interest in increasing the cardiologist’s “productivity”, it was obvious that all non-pacemaker communication and coordination of care was going to be kept to a minimum.
My mom’s primary care doctor (who unlike the cardiologist is not employed by the hospital) was given the “duty” of medication reconciliation by the hospital when my mom was ready for discharge. At that time, the primary care doctor simply wrote prescriptions for the heart-related new drugs and the old drugs sporting new dosages as well as one.other change to a non-heart-related drug.
Business-centered practices in healthcare businesses can have irritating (and even unsafe) ramifications to healthcare consumers. One such ramification became obvious to me after my mom went home with new prescriptions. I had to “correct” business–centered prescription and medication reconciliation practices that allowed the cardiologist not to take ownership for the heart-related prescriptions he had ordered and my mom needed after her hospitalization.
Medication Reconciliation and the hospital formulary
My mom’s recent hospital stay taught me that new drugs prescribed during a hospital stay are largely determined by the interests of the prescribing doctors, the hospital, and the pharmaceutical companies who supply the hospital with their formulary drugs. The new drugs prescribed in the hospital (drugs 5 and 6 in the figure above) came from the hospital formulary (and not my mom’s Medicare Part D plan formulary). The prescribing doctors in a hospital have tremendous power to replace old drugs with newer (more expensive, but not necessarily better) drugs, to use drugs that the doctor prefers, and to add drugs from the hospital’s formulary that are not cost-effective for the patient after they leave the hospital. These doctors are influenced (or often required) to prescribe the drugs found on the hospital formularies by pharmaceutical companies and the hospitals they are “affiliated” with.
When setting up its formulary, the hospital (unlike Medicare) can negotiate for better prices with pharmaceutical companies for its drugs. Therefore, a new drug a patient is prescribed from the hospital formulary might be a “deal” for the hospital but not for the patient. Many of the “deals” the hospital negotiates turn out to be higher (costlier) tier drugs in Medicare Part D plans that take over after the patient is discharged. It is left to the patient (or their patient advocates, if they are lucky to have one) to hunt down less expensive alternatives after discharge. I wonder how many patients do not know they can request substitutions that are more cost-effective?
Medication Reconciliation Summary
Medication reconciliation in a hospital is one of those business-centered practices that have huge ramifications to the healthcare consumer’s well-being. It is insufficient to assume that you have been given an accurate and optimum list of prescription drugs needed, especially if your drug list has changed as a result of the hospitalization. Some of your new prescription drugs may have been needed only for short duration in the hospital setting and not needed after discharge.
In addition, medication reconciliation does not take into account increased costs associated with choosing drugs from a hospital’s formulary rather than from a healthcare consumer’s drug plan formulary. Chances are good that any new prescription drugs written in the hospital are not the most cost-effective choices based on the healthcare consumer’s prescription drug insurance plan. It is good practice to always have your prescription drug plan’s formulary with you in the hospital so that your drug choices can be made based on what is most cost-effective for you and not what financially benefits businesses.