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Many organizations are uncertain about how to proceed with designing a workable solution for medication reconciliation. This chapter provides helpful information and tools for designing or redesigning a medication reconciliation process including:

• Guiding principles for designing a successful medication reconciliation process.
• "One Source of Truth."
• Defining roles and responsibilities for medication reconciliation.
• Integrating medication reconciliation into existing workflow.
• Flowcharting the design or redesign for medication reconciliation.
• Designing the process—considerations for various practice settings.
• Examples of electronic, paper-based, or hybrid (electronic plus paper-based) systems.

Guiding Principles for Designing a Successful Medication Reconciliation Process

These essential principles should be considered as you design the medication reconciliation process:

• Develop a single medication list ("One Source of Truth"), shared by all disciplines for documenting the patient's current medications.
• Clearly define roles and responsibilities for each discipline involved in medication reconciliation.
• Standardize and simplify the medication reconciliation process throughout the organization, and eliminate unnecessary redundancies (the flowchart of the current process can help you identify these redundancies).
• Make the right thing to do the easiest thing to do within the patterns of normal practice.
• Develop effective prompts or reminders for consistent behavior if true forcing functions (i.e., required reconciliation step presented to the physician during admission order entry within an electronic health record [EHR] are not possible.
• Educate patients and their families or caregivers on medication reconciliation and the important role they play in the process.
• Ensure process design meets all pertinent local laws or regulatory requirements. Linking medication reconciliation to other strategic goals (e.g., heart failure publicly reported process of care measures related to discharge instructions on medications) and/or other initiatives (e.g., a hospital project working on improving patient satisfaction related to pain management or patient communication regarding medications) when appropriate can also strengthen the importance of this process.

"One Source of Truth"

Medication reconciliation process design should center on the concept of a single list to document patient's current medications. This will be referred to as "one source of truth." This list should be shared and utilized by all physicians, nurses, pharmacists, and others caring for the patient.

• All disciplines caring for the patient should be working from the same medication list, regardless of the format (electronic or paper-based).
• The list should be centrally located and easily visible within the patient's medical record.
• This list becomes the reference point for ordering decisions and reconciliation, screening medications to be administered during a procedure/episode of care, and determining the patient's medication regimen upon discharge.  
• Each discipline should have the ability to update the home medications as new or more reliable information becomes available.
• In a paper-based format, old or modified information could be crossed out, new information can be added, and each change can be dated, timed, and signed.
• In an electronic system, changes would be date and time stamped, and the prescriber's name automatically captured. If the patient's medication list requires changes at discharge, updated information will remain stored for review and modification for future admissions.

Samples of "One Source of Truth" to document and verify a patient's current medications upon admission to the organization are in Figures 3 and 4.

Defining Roles and Responsibilities for Medication Reconciliation

Now, it's time to determine which discipline(s) should be involved in each step of the medication reconciliation process, including their respective roles and responsibilities. Consider some of the following questions:

• Which discipline could start building the "One Source of Truth" upon admission (entry) to the organization? How will information be validated as necessary toward establishing a "good faith effort" in building an accurate, complete medication list?
• What process steps are needed to perform medication reconciliation on outpatients and inpatients upon admission (entry), intra-hospital transfers (if applicable during a patient's stay), and discharge (exit)?
• What are the required elements for The Joint Commission's National Patient Safety Goal on medication reconciliation?
• What resources are available within the organization to perform required steps in the process?

During admission and at any point during the episode of care, various disciplines may learn new information regarding a patient's home medications. In addition, physicians, nurses, and pharmacists have an active role in reviewing, managing, and monitoring a patient's medications. Therefore, consider adopting a team approach for medication reconciliation. Remember, for a team approach to be effective, it is imperative that roles are clearly defined. If there is ambiguity around an individual's role, the process cannot be successful. To help drive this point home, here is an often-shared story about four people: Everybody, Somebody, Anybody, and Nobody.

"There was an important job to be done and Everybody was asked to do it. Anybody could have done it, but Nobody did it. Somebody got angry about that because it was Everybody's job. Everybody thought Anybody could do it, but Nobody realized that Everybody wouldn't do it. It ended up that Everybody blamed Somebody when actually Nobody did what Anybody could have done." (Anonymous)

Therefore, individual roles and responsibilities need to be clearly defined and understood by all disciplines participating on the medication reconciliation team.

To help determine roles and responsibilities, map out the various admission points in your organization. For procedural areas, consider clinics involved with pre-procedural appointments or areas that register patients and may be able to contribute to your process. Your list may look something like:

• Direct Admission (usually from a doctor's office) → Inpatient Unit.
• Procedural Area or Ambulatory Surgery Unit (pre-registered, early morning admissions) → Inpatient Unit.
• Emergency Department → Inpatient Unit.
• Triage/Labor and Delivery Unit → Inpatient Obstetrical Unit.
• External Transfers (patients transferred from an outside hospital) → Inpatient Unit.

Go to the Appendix for a sample worksheet and for an example of admission, intra-facility transfer and discharge process steps to determine disciplines roles and responsibilities for medication reconciliation.

Second, determine which discipline(s) within each admission point could initiate building the "One Source of Truth," and then confirm the list with the patient for accuracy and completeness. A good-faith effort should be made toward this goal with staff understanding of expectations.

Third, make sure you communicate roles and responsibilities for medication reconciliation clearly and effectively. After determining which discipline will be responsible for implementing medication reconciliation at certain admission points, make sure to update the policies and procedures to reflect this designation.

Integrating Medication Reconciliation into Existing Workflow

Prompts to complete required steps for medication reconciliation are essential. To be effective, prompts or reminders need to occur during the appropriate time within the clinician's workflow. Also, prompts or reminders decrease reliance on memory to perform required steps.

Incorporating prompts or reminders into a clinician's workflow is one example where automation is beneficial. For instance, during the admission order entry phase for a newly hospitalized patient, a physician could be prompted to complete medication reconciliation by documenting the patient's pre-admission medications and indicating ordering decisions for each medicine (i.e., continue, discontinue, modify, etc.). When the physician signs off on the admission order set, this could trigger a task for the nurse and/or pharmacist to communicate and educate the patient regarding new medications that were added or changes that were made in relation to desired treatment plans to identify unintended discrepancies.

If an organization has a paper-based system, medication reconciliation forms should be kept in the medical record in a highly visible, specified location to serve as a reminder to perform medication reconciliation during the episode of care. Regardless of practice settings, clinicians need effective reminders at the appropriate times within their workflow for consistent behavior if true forcing functions are not possible.

Flowcharting the Design or Redesign for Medication Reconciliation

Once roles and responsibilities are established and you've determined how the new design or redesign of an existing process can be integrated into workflow, a flowchart can be created. This new flowchart should be compared to the initial flowchart developed before redesign to highlight efficiencies through streamlined process steps and integration into existing workflow with consideration to transition points as applicable.

Designing the Process—Considerations for Various Practice Settings

Finding a starting point for improving the medication reconciliation project should be driven by understanding the needs of various departments and clinical roles and responsibilities of staff at each transition point is a great way to begin. Below are various transition points that should be considered as you build a plan to improve the medication reconciliation process.

Inpatient Practice Setting. One goal for medication reconciliation is to standardize and simplify the process throughout the organization. Often, nuances within various practice settings create challenges for medication reconciliation when patients transition through the hospital. It is important to recognize and understand these nuances, modify them as appropriate to minimize variations, and then integrate them into the overall process design. Begin by designing a core or primary process.

• How can each of the admission points be integrated into a primary or core process?
• Could one or more disciplines within each admission point initiate a "One Source of Truth" or confirm the list with the patient for accuracy and completeness?

Often, the flowchart is the primary process that encompasses the most high-volume entry points into the facility. Sample flowcharts by practice setting are provided for reference in the Appendix.

"One Source of Truth" Ambulatory Surgery or Procedural Area, the Emergency Department, and Triage/Labor and Delivery Unit. Ambulatory surgery can be a successful starting point of the "One Source of Truth" medication list. It is a relatively controlled environment that pre-schedules patient-nurse interactions and that commonly encompasses a medication review with each patient. In most cases, the patient is not acutely ill and can provide accurate information when given adequate time. Piloting the improved process in this department is a good way to establish the culture of using a "One Source of Truth."

Post-Acute Care Settings. While the majority of discussion and examples within this toolkit focus on inpatient settings, post-acute care facilities can adapt the same concepts to strengthen or implement a medication reconciliation process. A skilled nursing facility would look at all the processes that are common conduits for nursing home placement. Using admission directly from a hospital as the core process, the facility could then look at all variations on admissions that are encountered and make changes to the core process similar to the examples provided. Some variables may include admissions directly from home, admissions and referrals from home with the involvement of a home health provider, and even respite stays.

Similarly, a home health care provider could define its core process as an admission directly from an inpatient hospital stay to the services to be provided. In mapping out their process, the home health care provider could determine variations to this core process (e.g., admission from a skilled nursing facility, admission directly from home) and then integrate these scenarios into the core reconciliation process.

While many health care facilities are not "fully" electronic, it is important to have a good understanding of the needs of the clinician workflow and the process, as well as have a sound understanding of each department's individual needs, as this will assist in the choice of an electronic system or to build a process once there is a choice of EHR.

Medication Reconciliation upon Admission, Intra-Hospital Transfer, and Discharge in a Hospital with an Electronic Health Record. The following examples provide guidance on incorporating an electronic medication reconciliation process that includes "One Source of Truth" into the admission, transfer, and discharge workflow in order to make the right thing to do the easy thing to do.  

Admission. A medication profile within a patient's EHR can serve as a "One Source of Truth" for viewing inpatient medication orders and a patient's prescription/home medication list all in one location. A medication profile could be pulled into forms or presented when patients' current medication lists are obtained and documented (i.e., making the right thing to do easier). (Go to Figure 5.)

Within an EHR, incorporating medication reconciliation steps into a physician's workflow may include:

• Building "One Source of Truth" that includes documentation and confirmation of a patient's current medication list with radio buttons to indicate the accuracy, completeness, and information sources utilized (evidence of a "good faith" effort for obtaining the patient's current medication information).  
• Ability to indicate the plan for each home medication (such as discontinuing, continuing, or modifying current medications) in relation to the intended treatment goals for the episode of care when placing medication orders.
• Prompts to complete medication reconciliation when placing an admission or post-op order set.

Depending on the care unit, incorporating medication reconciliation steps into the nurse and/or pharmacist workflow may include:

• Receiving a task after the physician completes medication reconciliation to verify home medications documented by the physician with the patient, family, or other sources.
  • Verification is an important step, as patients often forget to mention medications or OTC medications/herbal supplements during the initial medication collection. Any new information regarding the patient's home medication list should be discussed with the physician and resulting changes documented.
  • This verification step also provides an educational opportunity to teach patients about the medications ordered for them in the hospital in relation to their home medications, and comment on any differences.
• Reconciling home medications with current inpatient orders.
• Clarifying unintended discrepancies (i.e., discrepancies that are not explained by the current care plan, by the patient's clinical status, or formulary substitution) with the physician for resolution.
• Completing a discipline-specific form with radio buttons and comment sections to document interactions and clarifications with patients, other sources, and the prescriber to trace follow-through on discrepancies and resulting clarifications and modifications, if needed. (Go to Figures 6 and 7.)

Intra-hospital Transfer. When a transfer order is placed indicating the patient is ready for transfer to another unit within the hospital, the physician may receive a prompt or reminder to perform medication reconciliation. Instructions may be included for the physician to:

• Assess current medication orders and make any changes or modifications in preparation for the new level of care.
• Review the patient's pre-admission medication list. Home medications initially held may now be appropriate to restart upon transfer.

Nurses and/or pharmacists may be involved during intra-hospital transfers to ensure medication orders for the new level of care are consistent with desired treatment plans and to provide an independent double check that pre-admission medications initially held are appropriately restarted.

Physician Prompting at Discharge. Physicians may be prompted or reminded to perform medication reconciliation when placing a "discharge order," indicating the patient is ready for discharge. A discharge checklist could also be created listing elements that need to be completed prior to discharge (e.g., remove heplock, perform medication reconciliation, prepare discharge medication list, educate patient, etc.). The goal for discharge medication reconciliation includes:

• Comparing the patient's pre-admission medication list with the patient's current inpatient medications.
• Updating the patient's pre-admission medication list to reflect the patient's medication regimen upon discharge. This list may be integrated into Discharge Instructions (for the patient) and Discharge Summary (for the next provider of service).
• Providing the patient/family with written information on the medications the patient should be taking when discharged from the hospital, or at the end of an outpatient encounter.
• Explaining the importance of managing medication information to the patient when discharged or at the end of an outpatient encounter. Instruct patient to:
  • Give a list to their primary care provider.
  • Update the list when medications are discontinued, doses are changed, or new medications (including OTC medications) are added.
  • Carry medication information at all times in case of an emergency.

Nurse and/or Pharmacist Prompting. Discharge medication reconciliation may be integrated within the nurse's and/or pharmacist's discharge workflow with a prompt or instructions to:

• Contact the physician if the patient's discharge medication list is not updated and/or complete (note: when establishing roles and responsibilities for preparing patients' discharge medication lists, a blanket statement such as "resume home medications" is not acceptable).
• Contact the physician to clarify patient questions encountered during the patient counseling session prior to discharge.

External Transfers. An external transfer patient is a patient who is transferred from a hospital outside of your own system. Such transfers may occur based on patient or provider request, specialty services required, or additional acute care needs.

External transfer patients have additional complexity in regards to medication reconciliation because three sources of information require review and reconciliation:

• Patient's list of medications prior to their hospitalization.
• Medications that are being administered to the patient at the outside hospital prior to transfer.
• Medications ordered at your hospital.

If the organization receives transfers from other hospitals, you should ensure a process is in place to address these reconciliation needs. Adequate communication and handoffs from the sending facility are critical to ensure all medication therapies are addressed and reconciled during the assessment and development of the patient's care plan at the organization.

Chapter 3 Lessons Learned

Lessons learned from staff of facilities that have implemented MATCH and facilities that received technical assistance on MATCH through the ´óÏóÊÓƵQIO Learning Network include:

• It is important to realize several key elements regarding medication reconciliation before getting started, especially as they apply to any practice setting (i.e., inpatient, outpatient) and any type of medical record system (i.e., electronic, paper-based, or both).
• There is no electronic substitution for a thorough medication interview with patients and/or their caregivers to obtain and verify current medication regimens. If patients and/or caregivers are able to participate in an interview, clinicians should ask what medications patients are taking and how they are taking them to identify discrepancies or uncover potential medication problems.
• Medication reconciliation should be an integral part of handoffs and communication during transitions in care.
• The patient plays a key role in medication reconciliation and should be educated on the importance of managing medication information at the time of discharge or at the end of an outpatient encounter. This education should include the importance of:
  • Giving a list to their primary care provider.
  • Updating their own list when medications are discontinued, doses are changed, or new medications (including OTC medications) are added.
  • Carrying their medication information at all times in case of an emergency:
    • This can help ensure patients are prepared to share an accurate medication list with their health care providers at each health care encounter.
• Enlist the support of primary care physicians and community pharmacists to encourage patients to carry and update their medication list at every encounter.
• Look for ways to make medication reconciliation a value-added process. Consider integrating medication review and reconciliation in daily rounds so medications can be reviewed at the point when clinical decisions are made and modified accordingly.