Mind the Gap…in Medication Management

For decades, passengers on the London Underground (“the Tube”) were warned to “mind the gap” by the omnipresent, automated male voice, cautioning them to avoid stepping into the significant – yet somehow often unseen – space between the edge of the platform and the subway train. Yet accidents still happened, and rider safety was threatened.

Not unlike this scenario, the healthcare community also strives to be aware of gaps – in this case, gaps in vital patient medication information. This is especially true in medication history and medication reconciliation where the sheer volume of medications per patient contributes to reconciliation struggles. For example, the average patient between the ages of 12 and 64 fills 12 prescriptions per year. That number more than doubles for patients over the age of 64.¹ When you add in the fact that approximately 20 percent of patients are receiving opioid prescriptions, it is easy to see how complex the issue becomes.²

With so many medications per patient, it’s not surprising that most single-source medication feeds – from a hospital, for example – fail to include a complete record of a patient’s medications. Providers incorporate patient-supplied information, but patients – and their family members – are typically unable to correctly identify all medications and all exact dosages. For certain medications, a memory “misstep” may lead to a potentially life-threatening adverse drug event.

As a starting point to closing this gap, healthcare professionals and health systems should embrace a comprehensive medication management solution, which combines medication history, medication reconciliation, and full electronic prescribing capabilities including electronic prescribing of controlled substances (EPCS). Effective medication management requires medication histories from throughout the patient’s continuum of care. Incomplete medication histories hinder a physician’s ability to make informed treatment decisions at the point of encounter and thus, may compromise patient care and safety.

Medication reconciliation at each patient transition of care is a standard component of the medication management process, as required by the Joint Commission and incentivized by CMS. Today, most providers utilize electronic health records (EHRs) and electronically prescribe legend drugs. A small but growing number of clinicians are also prescribing controlled substances electronically. Despite the widespread use of technology, the medication reconciliation process is imperfect at best.

In order to minimize medication gaps, providers must incorporate third-party sources of aggregated patient medication histories. Healthcare organizations have the ability to tap into multiple non-aggregated sources of medication histories in an attempt to make their data more complete. These sources may include e-prescribing records, pharmacies, PBMs, HIEs, and commercial and government payers. However, in order to be usable, histories must be reconciled, which can be a nearly impossible task because data sets are rarely compiled and made available in a consistent manner.

Organizations will typically find that multi-sourced medication histories are messy and incomplete. Medication history sources typically do not supply patient instructions for medications. If patient instructions are supplied by the source, more often than not it is supplied as free text. Serious medication errors may result. For example, free text patient instructions could be inaccurately transcribed into the medical record, leading to confusion and errors once presented to the provider. Errors can also occur when drug data dictionaries are poorly defined or when an EHR has only rudimentary e-prescribing capabilities and limited clinical decision support.

Fortunately, new technologies are making it easier to create and maintain clean source data, which in turn, simplifies the process of reconciling data from multiple sources. Additionally, the data gathered via leading edge technologies is more complete with enhanced drug sets and sig fields (with discrete data elements vs. text). Furthermore, these technologies enable varying data sets to be more easily combined and seamlessly presented within provider workflows, contributing to increased patient safety.

Providers must challenge their organizations, pharmacy leaders, and vendors to pursue a holistic view of medication reconciliation and to prioritize it as a strategic objective worthy of multi-departmental and cross-functional collaboration. If necessary, providers should be offered targeted, evidence-based incentives to encourage them to reach beyond their individual organizations to obtain relevant patient information that promotes safer, more cost-effective care.

As healthcare stakeholders collaborate in the hopes of realizing meaningful advancements in medication management and patient safety, they may wish to heed the message from across the pond – and Mind the Gap.

1. KFF.org http://kff.org/other/state-indicator/retail-rx-drugs-by-age/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D
2. Daubresse M, Chang H, Yu Y, Viswanathan S, et al. Ambulatory diagnosis and treatment of nonmalignant pain in the United States, 2000 – 2010.  Medical Care 2013; 51(10): 870-878