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Medication Reconciliation, CPOE and Patient Safety: One Physician’s Viewpoint

One persistent challenge in our industry is the need to come to a consensus around the concepts of medication reconciliation, computerized physician order entry (CPOE), and even patient safety. To some these concepts may seem obvious to define, but in reality they mean very different things depending who you ask. Today’s IT systems, at their best, should be applied to unify these seemingly disparate concepts.

The many hoops of medication reconciliation

When medication reconciliation hit the scene a few years ago, it was considered a new concept. Clinicians were told to gather an accurate medication history, make sure this history was available to everyone, and to review this data prior to making any management decisions impacted by medication use. We all learned these steps in medical school—the concept of reconciliation was not new at all. The problem was that there was no process in place to ensure it happened consistently and accurately. Many electronic systems today still don’t address this deficiency. They create a long, drawn-out protocol where, in addition to doing the work they normally do—taking a history, writing notes, creating orders, etc.—clinicians must then click on additional screens to perform medication reconciliation, even though mentally they have already completed this process. Understandably, this seems redundant and inefficient to the clinicians, who don’t believe this additional work makes their care better or safer. In fact, because it reduces efficiency and creates redundant work, the quality and safety of care actually suffers. For system implementation to truly be successful, organizations need to think more broadly about medication reconciliation and how it impacts clinicians and their patients. Medication reconciliation software should be much more than a list of medications. It should serve as a conduit for improved communication among the entire healthcare team, across the continuum of care. It should also serve as a tool to enhance patient understanding, compliance and safety.

The isolationism of computerized physician order entry

The value of CPOE has little to do with the fact that physicians are actually doing the ordering. You gain little, aside from improving legibility of orders, by turning physicians into clerical staff. The real value is that having physicians engaged in the ordering process standardizes practices and facilitates communication between providers. This is also true for other clinicians, including nursing staff and pharmacists. One of the major challenges of CPOE is that the systems tend to be isolated, and used or viewed only or primarily by physicians. The process of admitting or discharging a patient, or just creating new daily orders, doesn’t only impact doctors. It involves a range of healthcare providers:  nurses, pharmacists, respiratory therapists, physical and occupational therapists, dietary staff and others. How can you expect to impact patient care and safety if you don’t engage the entire team of providers using a comprehensive, multidisciplinary approach? Current CPOE systems don’t accomplish this. They are designed for docs. Period.

The other major barrier to successful CPOE is workflow inefficiency and redundancy. It simply takes the physician too long to complete the orders process. The argument is that while it may take a little longer, it will result in better and safer care. I would argue that the opposite is true:  If physicians must spend time on unnecessary tasks and repeat steps, if common tasks become complex, or if physicians are required to complete additional steps after interacting with the CPOE system, patient care and safety are sacrificed.  CPOE must “think like a doc” and intuitively support the decision-making process. CPOE should save valuable time, rather than take time away from patient care. CPOE should also ensure that orders are accessible to the entire healthcare team.

Compromising efficiency for patient safety

I have heard many discussions of patient safety systems hat supposedly deliver or support patient safety. It is often said that to achieve patient safety, you have to sacrifice clinician efficiency. I strongly disagree. Clinician efficiency and patient safety are intimately linked. If it takes a doctor twice as long to write orders, patient safety is sacrificed. If it takes a nurse twice as long to complete a medication history, patient safety is sacrificed. If it takes a pharmacist twice as long to review orders for accuracy, patient safety is sacrificed. Until IT systems—and the organizations that implement them—start making clinician workflow and efficiency a top priority, there will be little impact on patient safety. The practice of medicine has become exceedingly complex and demanding for caregivers at all levels. They simply don’t have extra time to absorb workflow inefficiencies caused by systems that hamper their efforts. It is the quality and safety of the care delivered that is sacrificed—ironically to the very systems designed to improve them.

The new trinity

Medication reconciliation, CPOE and patient safety should all be part of the same discussion. These concepts are very closely intertwined. For medication reconciliation to truly impact the quality and safety of patient care, it must be integrated into the ordering and medication management process. Physicians can’t be asked to “do orders” and then “do med rec.” A robust system should facilitate the physician thought process and decision-making process as the patient is evaluated and orders are created. It should ensure accurate and complete medication history charting by nursing staff, and help identify gaps and support process improvement when steps are missing or delayed. It should help pharmacists quickly review orders for safety. And it should provide alerts to communicate to doctors and nurses when something is not correct.

High-risk medication management, such as anti-coagulation therapy, is an important example that illustrates this interdisciplinary problem. Patients on warfarin therapy must be monitored closely by all members of the healthcare team. Physicians need to write orders in a structured way that ensures, in addition to safe medication orders, appropriate labs, diet and activity orders are in place. These orders need to be “refreshed” regularly by the physician—small changes in the condition of a patient on anti-coag therapy can have profound impact. Pharmacists need to be able to quickly and easily review all patients on warfarin therapy; checking orders, administrations, labs and other orders for accuracy and safety. Nurses need to know all the critical values to monitor for these patients before administering the medication, and be able to alert physicians and pharmacists if anything is abnormal or concerning.

A complete medication reconciliation solution must go far beyond providing a list of medications. It needs to enable and support providers in consistently delivering optimal care. Some might say this is not med rec but rather CPOE. But most CPOE systems do not engage the entire team of caregivers in this multidisciplinary way. What I describe here crosses traditional definition boundaries and could be best described as a patient safety platform. It is medication reconciliation. It is CPOE. It is nursing documentation. It is a pharmacy monitoring system. But above all, it actively improves patient safety.

How we get there from here

Organizations must first define specific patient safety goals, and then ask what must be required of a system to help an organization accomplish those goals. Analyzing the process is equally important as purchasing the right system. Organizations should define specific measures of success. They must ask the hard questions:  Will we really make patient care better? What defines “better care”? Will this system help us reduce errors? Will it make care safer in some other way? Will we improve efficiency and reduce redundancy? Exactly how and where? Will we improve communication? Will we improve clinician and/or patient satisfaction? How will each of these be measured and quantified?

I, for one, am weary of hearing that doctors’ lack of acceptance of computerized systems is the problem. It is often said that doctors “aren’t ready” for systems or that it takes a cultural shift to get doctors to practice differently. If online banking or shopping took me twice as long as running down to the local branch or grocer, and at the end of the transaction I wasn’t sure if it really went through correctly, I would never become an adopter. I would be resistant and noncompliant. Not because I wasn’t “ready” for computerization. Not because a cultural shift was required to make me bank or shop differently.

In fact, systems shouldn’t make doctors practice differently. Systems shouldn’t define the practice. Systems should—and must—facilitate and support best practices:  practices defined by clinicians and their organizations.

Dewey Howell, MD, PhD, a practicing family physician turned software developer, is the founder and CEO of Design Clinicals. Dr. Howell earned doctorates in both immunology and medicine at Baylor College of Medicine in Houston, Texas. Design Clinicals is a medical software company dedicated to creating clinician-friendly solutions for improved clinical effectiveness, communication and patient safety.