The entrepreneurial pharmacist has the responsibility of creating the value proposition for providing medication reconciliation.
"Entrepreneurs are simply those who understand that there is little difference between obstacle and opportunity and are able to turn both to their advantage." — Niccolo Machiavelli
Medication reconciliation certainly qualifies as an obstacle. The question is, who will see this as an opportunity to turn to their advantage? Medication reconciliation would appear to be an issue in which pharmacists should have a strong interest, and an area where we have some unique technical expertise. In 2012, Steeb and Webster co-authored an American Pharmacists Association/American Society of Health-System Pharmacy– sponsored white paper, “Improving Care Transitions: Optimizing Medication Reconciliation,” articulating well the need for medication reconciliation and the pharmacist’s unique effectiveness in conducting medication reconciliation. The next task for pharmacy—and this will be the responsibility of entrepreneurial practitioners—is to create the value proposition for pharmacist-based medication reconciliation.
A reasonable first step in understanding how one might convert obstacles to opportunities is to develop an understanding of the current environment. Where did medication reconciliation come from and where does it stand today?
As pharmacists, we have always had a sense of the concept of medication reconciliation. However, the first time this concept captured national attention was in 1999 with the publication of the Institute of Medicine’s (IOM’s) landmark study, “To Err Is Human.” “To Err is Human” articulated the magnitude of medical and medication errors produced by the health care system and called for system changes, providing “moral authority” for the development of formal medication reconciliation systems.
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) gave the IOM’s call for system changes “teeth” in 2005 when it published National Patient Safety Goal 8 (NPSG 8)-Medication Reconciliation. NPSG 8 required that hospitals accurately and completely reconcile medications across the continuum of care.
Specifically, NPSG 8 required that the hospital have in place a process whereby upon admission, transfer from service to service, and at discharge the patient’s medications from the previous “site” of care are compared with the medications ordered at the new “site” of care and any discrepancies (ie, omissions, duplications, adjustments, deletions, and additions) are reconciled and documented. In 2008, JCAHO added the additional requirement that the complete list of medications is also provided to the patient upon discharge from the facility.
As hospitals struggled to develop and implement effective and efficient medication reconciliation processes, in January 2009 JCAHO determined that survey findings on NPSG 8 would continue to be evaluated; however, its requirements would be evaluated and refined. The updated guidelines for JCAHO-accredited organizations were streamlined (5 performance elements vs 17 in the previous version) under NPSG 03.06.01, which became effective July 1, 2011.
The Health Information Technology for Economic and Clinical Health (HITECH) Act further institutionalized the concept of medication reconciliation. HITECH, under its mandate to improve care quality, efficiency, and safety through the promotion of health information technology (HIT), instituted meaningful use (MU) objectives. Under HITECH, eligible providers (EPs) and hospitals can obtain Medicare and Medicaid incentive payments for adopting HIT that achieves MU objectives. One of these objectives is the medication reconciliation objective, which requires that the EP perform medication reconciliation for more than 50% of the patients received from another care setting/care provider or in the event they believe medication reconciliation is relevant.
Moreover, this objective requires that the reconciliation is conducted using certified technology that provides for the comparison of multiple medication lists. During Stage 1 of MU implementation (2011-2012), the medication reconciliation objective is optional; however, in Stage 2 (2014), where more rigorous exchange of health information will be required, it is expected that there will be a higher bar for achieving meaningful medication reconciliation.
What are some perspectives you might take away from this brief description of the current environment?
There is a national movement to deploy medication reconciliation systems.
EPs and hospitals are currently the accountable entities for assuring that medication reconciliation is provided.
The national standards for conducting medication require that medication lists be transmitted electronically and aggregated for comparison.
What might today’s pharmacist-based medication reconciliation product look like? It might have to:
Be a component or be able to “bolt onto” the care system of an EP or hospital
Provide reconciliation both at admission and at discharge
Accept medication lists in a community standard format
Provide user interfaces and rules sets for comparing lists and identifying medication discrepancies
Provide work flow functionality for reconciling identified discrepancies
Identify patients who require medication reconciliation outside of a care transition
Transmit a reconciled medication list in a community standard format
Provide all of the above with more value (less resources consumed per unit of output delivered).
To be sure, this is a tall order—but this is the type of challenge that energizes entrepreneurs.
James Notaro, BSPharm, MS, RPh, PhD, is the founder and president of Clinical Support Services, Inc, in Buffalo, New York. He has developed several innovative and proprietary systems that offer various sectors of the health care industry the opportunity to improve patient care while obtaining a demonstrated savings in time and costs. His background is diverse, including experience throughout the health care continuum from clinical operations to managed care administration to academia to entrepreneurial endeavors. A graduate of Albany College of Pharmacy, he completed a master’s degree at Union University and received his PhD in operations research from the University of North Carolina at Chapel Hill. A licensed pharmacist in New York and North Carolina, he currently is an owner/ partner of Buffalo Pharmacy Group, Inc, which operates 5 independent ambulatory-care pharmacies in the southern suburbs of Buffalo.