Communities Making a Difference, Part 2:
Managing Medications in Montreal
The RightRx Project
Poor efforts at managing medications remain a major patient safety issue in the U.S. In the e-Book Med Wreck..., we champion the formation of a national medication repository to create a single source of truth for every patient. We can learn from what others are doing in order to anticipate challenges and opportunities. This article reviews a Canadian effort for managing medications as published in an October 2017 article in JAMIA. They integrate community drug data with a medication reconciliation tool (RightRx). They share their "lessons learned" in the process.
The Importance of Using a Community Model
The researchers at McGill University (Robyn Tamblyn, Ph.D., Nancy Winslade, PharmD, Todd Lee, MD, et al. Reference below.) set forth to create and validate a web-based application (RightRx) for the electronic reconciliation of medications (med rec) during hospitalization. As patients presented to hospital, RightRx prepopulated their medication list through integration with the dispensing drug database for the 8.5 million citizens of the Province of Quebec.
The clinicians in this study were paper-based, i.e. did not have an EHR. They performed medication reconciliation with the RightRx application prepopulated with the provincial drug dispensing history for the patient. The hospital pharmacy information system (GE Centricity) also updated the RightRx medication list. Thus, this study somewhat simulates the statewide model for managing medications recommended in Med Wreck... for maintaining a single source of truth for the patient's list of medications. However, this study did occur in a setting that had poor rates of med reconciliation completion prior to the study.
The researchers understood change management
The authors reported that they were able to improve medication reconciliation rates by as much as 9-fold. Even during the study, they doubled the rate of med rec between their control and intervention groups (P-value <0.0001). They named several factors for their success.
"Support was provided by senior hospital and clinical unit leadership, clinical champions existed at the unit level, field staff provided ongoing training and feedback to the scientific and development team about technical, usability, and professional issues, weekly adoption rates were analyzed, and the development team responded to modify the application and system to address priority issues."
In this statement we see that they engaged their leadership and end-users, communicated well, and adapted to stakeholder needs and values.
The researchers did measure the mean duration of time various stakeholders (physicians, pharmacists, nurse practitioners, nurses, medical/pharmacy students) accessed the RightRx application. There appeared little difference between internal medicine doctors (who had been more proficient with med rec.) and cardiac surgeons.
They were able to group the patient's inpatient medications and outpatient medications by drug class rather than alphabetically, which helped to identify therapeutic duplicates.
They initially had issues with physicians performing discharge med rec with their original design, requiring them to create a new label for continuation of home medications following hospitalization. (As voiced commonly in the U.S.,) Hospital physicians at the time of discharge med rec preferred to mark home medications as "continued as prior to admission" rather than imply that they had responsibility for the patient's home medications prescribed by others.
They did not use standardized structured data for drug name, dose, frequency and route, which we would standardize in the U.S. to RxNorm. This provides better integration for computerized provider order entry in an EHR environment.
They appreciated the need for historical data showing prior clinical decisions and reasoning behind medication changes. They adapted the RightRx application to display historical changes with a single mouse click.
Even though they compiled the list of medications from the dispensing drug database for the province, they still validated that list with the patient.
They did not make a "patient-friendly" output list from their application, but suggest it as a future enhancement.
Implications for the U.S.
This study adds to our understanding that there are opportunities to make med rec more efficient and safe. Leveraging a common source of truth for the patient's medication list creates efficiency for admission medication reconciliation. Also that list was updated through the pharmacy information system throughout the hospital stay to create a unified list for discharge med rec. In the U.S. there are still multiple sources of contribution for each patient's list of medication, making it more difficult to sort and assimilate a single, accurate list. Hopefully studies like this will move us toward adoption of a national repository to address the high costs and patient harms that occur from our current state of "Med Wreck." This could lead us to a more efficient, safer system of managing medications.
Is our final segment on "Communities making a difference," we will look at how the Oregon VA uses patient kiosks to empower patients to update their medication lists.
Tamblyn R, Winslade N, Lee TC et al. Improving patient safety and efficiency of medication reconciliation through development and adoption of a computer-assisted tool with automated electronic integration of population-based community drug data: the RightRx project. JAMIA. 0(0), 2017, 1-15 [Abstract]
The Canadian Institutes of Health Research (CIHR) and the Canadian Foundation for Innovation (CFI) provided funding support for the RightRx project. The McGill University Health Centre joined in partnership with the Ministère de la santé des services sociaux du Québec for this project.
Catch Part 1 of Communities Making a Difference [CLICK HERE] and learn about Medication Harmony at Harvard.