MedRec Process in Primary Care Practice Settings
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.
Select the patients who will undergo MedRec
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
Consider involving administrative staff to assist in identifying patients who meet the criteria for MedRec. For example, when a patient calls to schedule an appointment following discharge from hospital, the administrative assistant can flag the chart to indicate that MedRec will be required.
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:
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:
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...
Compare the BPMH with the patient's chart
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:
The following are examples of specific discrepancies:
The following factors have been identified as predictors of discrepancies: 17
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.
Table 1: Examples of Harm Resulting from an Unreliable MedRec Process
Correct the discrepancies identified
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:
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:
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 the reconciled list
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
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.
Figure 5: Medication Reconciliation in Primary Care
MedRec within the Patient's Circle of Care
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:
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.
Many other players in the primary care sector in Ontario have made MedRec a priority, including the following:
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)
Primary Care Practice Settings
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.
Table 2: Examples of Change Ideas to Facilitate Medication Reconciliation (MedRec)
Quick improvements you can start today:
Improvements you can start within a couple of months:
Longer-term process improvement goals:
Refer to Appendices 6 to 8 for further information on implementation strategies, measurement and quality improvement resources.
Table 3: Challenges to Completing Medication Reconciliation (MedRec) in Primary Care Practice Settings
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?
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