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Primary Care MedRec Guide
Medication reconciliation is a multi-step process that is best accomplished through an interprofessional approach.25,26 It can be applied to a variety of practice settings, although adaptations may be required to ensure the process meets the needs of individual practice settings.
Before a MedRec process for primary care is developed and implemented, it is important to determine who will perform each step. The entire process could be carried out by the individual primary care provider or, ideally, at least some of the steps would be carried out by others working in the practice (e.g., nurse, pharmacist, clerical staff).
The first step of the MedRec process is to collect the BPMH and to compare it with the information in the patient's chart. Differences or discrepancies between these two sources of information are identified and resolved. The crucial next step involves updating the patient's chart with the reconciled list and communicating this reconciled list to the patient and others involved in the circle of care. The nature of primary care also necessitates that the current medication list be reviewed and updated at all subsequent patient visits.
Ideally, MedRec will be performed for all patients within a practice. However, given the resource-intensive nature of this intervention, completing MedRec for all patients may be challenging. As such, it may be more practical to establish criteria to determine which patients within a practice are most likely to benefit from MedRec.
The following patient groups might be selected for MedRec: 19,27,28
- patients who have recently been discharged from hospital
- patients who are taking more than a threshold number of medications
- patients who are older than a threshold age (i.e., 65 years old)
- patients who are taking high-risk medications
- patients who are new to the practice setting
- patients with diagnosis of an ambulatory care sensitive condition
- patients who meet certain eligibility criteria as defined for the particular practice setting
- patients who are scheduled for annual physical examination
Collect the Best Possible Medication History (BPMH)
The first step of the MedRec process in any care setting, including primary care, is to collect the BPMH.
Obtaining the BPMH involves gathering information about the patient's medication regimen from various sources and interviewing the patient or a caregiver.
Gather information about a patient's medication regimen from the various sources in advance of the interview. Having the information ahead of time can facilitate a smoother interview process.
Sources of medication information that may be available for review include the following:
- medication vials or blister packs
- medication list from community pharmacy
- MedsCheck records from community pharmacy
- Ontario Drug Benefits drug profile viewer
- hospital discharge summary
- BPMH prepared by Rapid Response Nurses
- Community Care Access Centre (CCAC) report
- specialist's consultation report
Each of these sources of information has benefits and limitations. Even sources that are not 100% accurate or complete may convey valuable information. (Refer to the section Sources of Medication Information for more details.)
Interview the patient or caregiver using a systematic process to establish the complete list of medications (including name, dose, route, and frequency) that the patient is taking. Here, it is important to determine the patient's actual medication use, especially if it differs from the prescribed use.
Actual medication use refers to how a person routinely takes his or her medications, which may differ from instructions provided by a healthcare professional or directions on the medication label. The actual medication use should be a more accurate representation of what medications the patient is consuming and how those drugs are being consumed. (Refer to Appendix 2 for the Top 10 Tips for Interviewing Patients)
The medication list should include all types of medications that the patient is taking, including the following:
- prescription medications
- nonprescription medications
- vitamins and supplements
- natural and herbal products
- traditional medications
- medications taken on an as-needed basis
- any other type of medication
Actual Medication Use is key to ensuring that an accurate history is obtained and will assist in the prevention of adverse drug events
Document the BPMH. For each medication, state the name, dose, route, and frequency. If it is determined that the patient is taking one or more of the medications differently from how it was prescribed, clearly document the actual medication use and note that it differs from the prescriber's original intent. (Refer to Appendix 3 for more tips on how to document a BPMH)
Bear in mind that it may be difficult to achieve an absolutely complete and accurate list of the medications that a patient is taking. Several attempts may be needed to obtain the list, and in some cases it may be impossible to get the complete list. The goal is to obtain the "best possible" list.
Before prescribing a drug, physicians must have current knowledge of the patient's clinical status. This can only be accomplished through a clinical assessment of the patient. The assessment must include:
a) An appropriate patient history, including the most complete and accurate list possible of drugs the patient is taking and any previous adverse reactions to drugs. A physician may obtain and/or verify this information by checking previous records and databases, when available, to obtain prescription and/or other relevant medical information; and if necessary...
Prescribing Drugs, Policy #8-12. December, 2012. College of Physicians and Surgeons of Ontario
Compare information contained in the BPMH with information in the patient's chart held by the primary care provider.
Identify any discrepancies between these two sources of information. This can be done during the interview or later, after the interview is complete.
Discrepancies are differences in medication details that are identified by comparing different sources of information about a patient's medications (including the patient himself or herself). Discrepancies may take various forms, such as the following:
- differences between what the patient is actually taking (actual use) and what is recorded in other sources of information (e.g., patient's chart, community pharmacy profile)
- differences between the list of medications that the patient was taking in one healthcare sector and the list of medications ordered or recorded in the next healthcare sector
The following are examples of specific discrepancies:
- absence from the list of a medication that the patient is currently taking (omission)
- presence on the list of a medication that the patient is no longer taking (commission)
- incorrect or missing details about a medication (e.g., dose, route, or frequency)
The following factors have been identified as predictors of discrepancies: 17
- older patient age
- certain physician specialties
- participation of another physician in the patient's care
- long duration of relationship between the physician and the patient
- large number of recorded medications
MedRec processes can decrease the potential for discrepancies leading to adverse drug events. They help healthcare providers to ensure that changes in medications are intentional and that discrepancies are identified, resolved, and documented.
| Source of Potential Harm to Patient | Examples of Specific Harms |
|---|---|
| Incomplete or inaccurate collection or documentation of patient's actual medication use |
|
| Unintentional changes to patient's medication regimen as medications are prescribed at transitions in care |
|
| Ineffective use of medication information to guide safe medication management |
|
| Ineffective communication with patient and care providers about changes made to patient's medication regimen |
|
Correct the discrepancies as appropriate through discussion with the patient or caregiver. Contact the original prescriber or the community pharmacy for additional information, if necessary. Depending on who is completing the BPMH, it may be possible to resolve or correct some or all of the discrepancies during the interview process.
Determine the cause of the discrepancy, as this information will assist with appropriate resolution of the problem. The following questions point to potential causes of a discrepancy:
- Determine the cause of the discrepancy, as this information will assist with appropriate resolution of the problem. The following questions point to potential causes of a discrepancy:
- Did a clerical error lead to the discrepancy?
- Did the patient intentionally choose to take the medications differently than prescribed, because of a side effect, on the advice of a friend, or on the basis of information found on the internet?
- Did the prescriber who initiated the medication not fully appreciate the other medications that the patient was taking?
Once the cause has been determined, engage in discussion with the patient, the caregiver, the community pharmacist, or the original prescriber to determine the best course of action. The following courses of action may be considered:
- If the patient prefers to take the medication as he or she sees fit and is unwilling to change, update the patient's chart to reflect that change.
- If the patient was unclear on how to take the medication but is willing to start taking the medication as prescribed, document this information in the chart.
- If there was a prescribing error and a change in medications is necessary to correct the error, change the prescription and document the change in the patient's chart.
The most important aspect in resolving discrepancies is to involve the patient in the process and to obtain his or her agreement on the appropriate course of action. If the patient is not in agreement, the discrepancy will be perpetuated once the patient leaves the office. Document any actions taken to resolve discrepancies.
Once the discrepancies have been resolved, update the BPMH to accurately reflect the patient's current medication regimen. This updated list becomes the reconciled list. It should serve as the most up-to-date and accurate version of the patient's medication list. Document the reconciled list in a clearly visible and easily accessible place in the chart.
Communicate any medication changes to the patient and verify the patient's understanding of the updated medication regimen. Convey to the patient the importance of keeping an up-to-date medication list. (Refer to Appendix 4 for patient resources).
Provide the reconciled list to the patient's community pharmacist and others involved in the patient's circle of care. On the reconciled list, convey to providers the rationale for any changes that have been made.
At each patient visit, ask the patient specifically about medication changes that may have occurred since the last visit. Ask about all medications that the patient is taking, not just medications related to the reason for the visit.
When a patient's medication regimen is modified, the changes should be reflected in the medication list maintained in the medical records of the primary care setting. Conversely, if no changes in the medication regimen have occurred, that should also be documented.
Such changes may occur when
- new prescriptions are added, discontinued, or modified by the primary care provider
- medication changes are made by a specialist or other physician (e.g., physician at a walk-in clinic)
- medication changes are recommended by another care provider (e.g., community pharmacist, nurse practitioner, dentist)
- a patient makes changes to the medication regimen of his or her own accord
The patient should be given an updated medication list, reminded to discard old lists, and educated on the importance of maintaining the medication list and making providers aware when medication changes occur.
The reconciled list should serve as the basis for any decisions to optimize safe and effective drug therapy and should follow the patient as he or she transitions throughout the healthcare system.
Depending on the resources available, the patient population, and other individual characteristics at each practice setting, the steps outlined above may not occur in the order presented here; in addition, in some situations, there may be a need to go back to an earlier step before proceeding to the next step. The most important outcome is an accurate and comprehensive medication list that is communicated to the patient, with verification of the patient's understanding of the regimen.
Requesting Referrals
When a patient requires services additional to those offered by the primary care provider (e.g., referral to specialist, initiation of CCAC services), a complete and up-to-date list of medications should be provided in the referral request, including the following details:
- all prescription and nonprescription medications recorded in the patient's chart (not only those medications that may seem relevant to the receiving provider)
- complete details about every medication (name, dose, route, frequency)
- medication allergies
Any medication changes that result from the referral should be reflected in the patient's chart held by the primary care provider on receipt of the information.
Receiving Referrals
Many other players in the primary care sector in Ontario have made MedRec a priority, including the following:
- Rapid Response Nurses
- telehomecare nurses
- home care pharmacists
- other CCAC workers
- community pharmacists who perform MedsCheck
The process of completing MedRec in these settings may necessitate involvement of the primary care provider. If discrepancies are identified, the primary care provider may be contacted for assistance in their resolution. In addition, the reconciled list that results from completion of MedRec in any of these settings should be sent to the primary care provider, and ideally, the patient's chart held by primary care provider will be updated accordingly. (Refer to Appendix 5 for an overview of primary care providers in Ontario)
Variations among primary care practice settings, (e.g., in terms of resources, staffing, billing models, geographic location), does not allow for one model of MedRec to be easily applied to all settings. Completing MedRec in a solo practitioner practice setting may be more of a challenge than performing the same task in a team-based practice setting. In any setting, incorporating various change ideas into the process can assist practitioners with implementing and sustaining this intervention.
- Use screening tools to direct MedRec efforts toward high-risk patients
- Develop a form or a specific section in the chart to document BPMH and the reconciled medication list
- Print medication lists from electronic medical record or patients' charts for patients to review in the waiting room before their appointments (for self-identification of discrepancies)
- Encourage patients to bring all of their medications to all visits
- Use teach-back method to verify patients' understanding of their medication regimens
- Complete MedRec within 14 days of a patient's discharge from hospital
- Complete MedRec after an emergency department visit
- Complete MedRec after a specialist visit
- Involve the team pharmacist in the MedRec process
- Provide community pharmacists with initial reconciled list
- Provide patients with tools to record and update their medication lists
- Liaise with community pharmacist to complete BPMH or MedsCheck
- Ask office administration assistant to call patients in advance of their appointments reminding them to bring their medication lists and medications
- Include a review of patients' medications in the intake process completed by nursing staff
- Use technology to facilitate and improve MedRec
- Initiate formal MedRec process during annual "check-up" visit
- Build Med Rec into the documentation workflow (e.g., review of specialists' notes for any medication changes or discrepancies, with such changes or discrepancies prioritized for review and resolution or update, as appropriate)
- Conduct MedRec for all patients in the primary care practice setting
Refer to Appendices 6 to 8 for further information on implementation strategies, measurement and quality improvement resources.
| Patient or Provider Level | System Level |
|---|---|
| Responsibility for medication management (rests largely with the patient) | Limited access to information sources |
| Limited health literacy on part of patient | Unreliability or incompleteness of information sources or existence of multiple conflicting sources |
| Language and cultural barriers | Difficulty of sharing information among providers |
| Patient's lack of awareness of importance of bringing medications and up-to-date medication lists to primary care visits | Poor design of electronic medical record systems used in primary care offices (insufficient to fully support MedRec requirements) |
| Patient's use of multiple pharmacies | Lack of availability of fully integrated provincial health record |
| Infrequent or periodic contact with primary care provider | |
| Lack of time for provider to complete MedRec | |
| Lack of training about conduct of systematic, comprehensive medication histories and reconciliation processes | |
| Effort and dedication required for frequent modification of list |
Figures 6 and 7 depict processes that could be implemented in primary care practice settings to facilitate MedRec. Not all of these processes (or steps within an individual process) will make sense in all settings. It is best to use small tests of change to determine what will work best in a particular setting. In addition, attempting to identify potential barriers to a given process in advance of its implementation may lead to smoother implementation. Even so, several attempts may be needed before the best process is fully elucidated. For example, determine your 10 most frequent patients and schedule a dedicated block of time to collect a BPMH from them, and then review the process: How receptive were the patients? How did the staff find the sources of medication information? How many discrepancies were identified?
