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Improving Efficiencies in
Medication Reconciliation - The
McGill Story
Review of Challenges and Potential Benefits of
Using IT-Enabled Medication Reconciliation
Robyn Tamblyn, BScN, MSc, PhD
Professor, Department of Medicine and Department of Epidemiology and
Biostatistics, McGill University, Faculty of Medicine

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Call Objectives
• Discuss the challenges in improving medication
reconciliation
• Describe what has been learned from IT
• Describe the assets to enable more efficient IT
in medication reconciliation in Canada
Identifying challenges in medication
reconciliation and assets to enable more
efficient medication reconciliation in Canada is
a priority.

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October is Canadian MedRec
Quality Audit month.
The MedRec quality audit month is designed to establish a
national perspective of the quality of admission MedRec in
acute and long term care facilities over a one month period.
By participating in the national audit, you will be part of a
movement to measure the quality of admission MedRec
processes which can decrease preventable drug events.
3

4. www.saferhealthcarenow.ca
Canadian MedRec Quality Audit month.
4
• Join us for a national webinar on October 1, 2013 at 12
noon ET to kick-off the Canadian MedRec Quality Audit
month.
• Register Now to participate in the Canadian MedRec
Quality Audit month (October 1 – 30, 2013). Please note:
Both registration and participation are complimentary.
A tally of audits will be unveiled at Canada’s Virtual Forum on
Wednesday, October 30th , a day dedicated to medication safety
across the continuum.

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We want to hear from you
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Today’s Speaker
Robyn Tamblyn, BScN, MSc, PhD
Dr. Robyn Tamblyn is a Professor in the Department of Medicine and the
Department of Epidemiology and Biostatistics at McGill University. She is a
James McGill Chair, a Medical Scientist at the McGill University Health
Center Research Institute, and the Scientific Director of the Clinical and
Health Informatics Research Group at McGill University.

7. Review of Challenges and
Potential Benefits of Using
IT-Enabled Medication
Reconciliation
August 2013

8. Background
Failure to reconcile pre-admission medication with medications
prescribed at discharge may contribute to preventable ADEs:
 19% to 23% of patients will have an ADE within 30 days of
hospital discharge1,2
 14.3% will be readmitted3
 Adverse drug events (ADEs) are preventable in 58% of the
cases 4
ADEs are the 6th leading cause of death at a cost over $5.6 million
per hospital per year 5
1. Forster AJ, Clark HD, Menard A et al. Adverse events among medical patients after discharge from hospital. CMAJ. 2004;170:345-
349.
2. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after
discharge from the hospital. Ann Intern Med. 2003;138:161-167.
3. Coleman EA, Smith JD, Raha D, Min SJ. Posthospital medication discrepancies: prevalence and contributing factors. Arch Intern
Med. 2005;165:1842-1847.
4. Leape LL, Bates DW, Cullen DJ et al. Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA. 1995;274:35-
43.
5. Bates DW Spell N, Cullen DJ et al. The costs of adverse drug events in hospitalized patients. Adverse Drug Events Prevention Study
Group. JAMA. 1997;277:307-311.

9. Challenges in implementing Medication
Reconciliation (MedRec)
1. Collect an accurate and comprehensive community-based
medication list (CML)
2. Conduct medication review on all patients at risk
3. Communicate consistently medication/dose changes at
discharge to the community care team

10. Number of prescribing physicians per patient at the time
of the ED Visit
Tamblyn et al, JAMIA, 2013

11. Number of pharmacies identified per patient at the time
of the ED visit
Tamblyn et al, JAMIA, 2013

12. Percentage of patients’ community medications that are
not documented in the hospital chart
Tamblyn et al, JAMIA, 2013

13. Need to
search for
pharmacy
coordinates
… Google,
Canada 411

14. Time (in minutes) to complete medication reconciliation
tasks at admission and discharge, per hospital unit

15. Computers

17. What has been learned from IT?

18. • Designed a medication reconciliation application: “The Pre-
Admission Medication List (PAML) Builder” and implemented it at
two 2 large Partners Healthcare academic hospitals in Boston
• Highlighted the need for order entry in addition to medication
information
Evaluation of an inpatient computerized
medication reconciliation system
Turchin A, Hamann C, Schnipper JL et al. JAMA 2008

19. •Integrated the “PAML builder” to a computerized provider order
entry (CPOE)
• Showed a 28% reduction in unintentional medication
discrepancies with potential for harm
•Non-integration of the PAML builder with the CPOE system at
discharge at hospital 2, showed less of a reduction in potential
adverse drug events compared to hospital 1
•Hospital readmission or emergency department visit within 30
days was 4% lower in the intervention group but not significant
Effect of an Electronic Medication Reconciliation
Application and Process Redesign on Potential Adverse
Drug Events A Cluster-Randomized Trial
Schnipper J. L et al. JAMA 2009

20. The EMITT Study: Development and Evaluation of a
Medication Information Transfer Tool
Cesta et al, The Annals of Pharmacotherapy, 2006
•A web based electronic tool designed by the University Health
Network in Toronto and integrated with the electronic patient
record (EPR) to facilitate the MedRec process
• Allows electronic documentation of patient medication history
on admission, generation of a discharge medication prescription
and a detailed medication information transfer letter
•A feasibility pilot of 40 orders involving nine pharmacists suggest
that EMITT is a functional and practical tool for transfer of
information between health care professionals and may
potentially decrease medication discrepancies

21. Reducing Medication Errors and Improving Systems
Reliability Using an Electronic Medication Reconciliation
System
Agrawal, Abha; Wu, Winfred Y., Joint Commission Journal on Quality and Patient Safety, 2009
•Designed and implemented an electronic Medication Reconciliation
“MedRecon” system that integrated with a CPOE system at Kings
County Hospital Center in New York City
•After implementation, the medication discrepancy rate was 1.4%
between community and hospital medications, compared to 20.1% in
a pilot sample of 120 encounters before implementation
•Demonstrated improved physician compliance from 34% to 84% with
“MedRecon” performance when using an interactive reminder alert

22. Medication reconciliation is a required
organizational practice for hospital
accreditation

23. MedRec Accreditation
2013
• Organizational Priority
• Implemented in 1
client service area at
admission, discharge
and transfer
• Documented plan to
implement throughout
the organization
2014
• Strategic Priority
• MedRec policy and process at
transitions of care
• Defined roles and responsibility
• Plan to implement and sustain
MedRec
• Plan is led and sustained by
interdisciplinary coordination
team
• Evidence of staff education

24. Rx
Rx
Rx
Rx
Rx Rx
Assets to enable more efficient MedRec
in Canada

25. Primary objectives:
To determine if automated transmission of community medications and IT-
enabled MedRec will reduce the risk of ADEs, ER visits and hospital
readmissions in the 30 days post-discharge by:
 reconciliation of community and hospital medications at discharge when
facilitated by electronic retrieval of the community list
 communication of treatment changes to the community-based
prescribing physicians and pharmacists
RightRx: Using Novel Canadian Resources to Improve
Medication Reconciliation
Tamblyn et al, McGill University: CIHR Research in Progress

26. Secondary Objectives:
To measure:
 Failure to re-prescribe chronic disease medications
 Therapy duplications
 Time to complete the MedRec process

27. Design:
 Cluster-randomized controlled trial
 Target population: publicly insured admitted adults to target
units at the Royal Victoria and Montreal General Hospitals
 12-months, 3714 patients

28. What can I do with RightRx?
1. Collect and evaluate patient’s :
 Community medication list (CML)
 Community pharmacy and prescribing physician coordinates
 In-hospital medication list
2. Conduct medication reconciliation and review
 At admission, transfer and discharge
3. Communicate consistently reconciliation decisions at discharge

29. Where does the information come
from?
 RightRx uses this “real-time” linkage to the
Quebec health insurance agency (Régie
de l’assurance maladie du Québec:
RAMQ) to retrieve information on
community medications and medical
services.

30. DATA FLOWS for RightRx
Patient consent
Receives hospital medication list
every 15min, 7/7 days, 6h-22h
Retrieves med list from
RAMQ
Medication
Reconciliation
Community list
Validation
Discharge prescription
Automatic transmission of
medication changes to community
pharmacies/physicians
MOXXI
servers
RAMQ
Database
Hospital
database
Signed printed prescription
brought to community pharmacy
RightRx
servers

31. Accessing RightRx through hospital
Electronic Health Record

32. The MedRec Process

33. 1. Collect and evaluate community
medication list

34. ‘Prior to Admission’ tab
Prior to admission Discharge
Admission
Review/Transfer

35. ‘Prior to Admission’ - Expanded view
Prior to admission Discharge
Admission
Review/Transfer

36. ‘Prior to Admission’ - Expanded view
Prior to admission Discharge
Admission
Review/Transfer

37. ‘Prior to Admission’ – Medication Validation
Prior to admission Discharge
Admission
Review/Transfer

38. ‘Prior to Admission’ – Validation of Adherence
Prior to admission Discharge
Admission
Review/Transfer

39. ‘Prior to Admission’ – Validation of Adherence
Prior to admission Discharge
Admission
Review/Transfer

40. ‘Prior to Admission’ - Validation of Adherence
Prior to admission Discharge
Admission
Review/Transfer

41. ‘Prior to Admission’ – Adding a medication
Prior to admission Discharge
Admission
Review/Transfer

42. ‘Prior to Admission’ – Adding a medication
Prior to admission Discharge
Admission
Review/Transfer

43. ‘Prior to Admission’ – Adding a medication
Prior to admission Discharge
Admission
Review/Transfer

44. ‘Prior to Admission’ –Validated list
Prior to admission Discharge
Admission
Review/Transfer

45. ‘Prior to Admission’ –Validated list

46. 2. Medication Review

47. ‘Admission Review/Transfer’ tab
Prior to admission Discharge
Admission
Review/Transfer

48. ‘Admission Review/Transfer’- In line validation –
Continuing a medication
Prior to admission Discharge
Admission
Review/Transfer

49. Prior to admission Discharge
Admission
Review/Transfer
‘Admission Review/Transfer’- In line validation –
Stopping a medication

50. ‘Admission Review/Transfer’- Reason for
Discontinuing
Prior to admission
Admission
Review/Transfer

51. Ordonnance pharmaceutique Medication Order
‘Admission Review/Transfer’- Finalized order
Tap water enema prn

52. 3. Discharge Prescription

53. ‘Discharge’-tab
Prior to admission
Admission
Review/Transfer

54. ‘Discharge’- In line validation – Continuing a medication
from hospital to home
Prior to admission
Admission
Review/Transfer

55. ‘Discharge’- In line validation – Stopping a medication
from hospital to home
Prior to admission
Admission
Review/Transfer

56. ‘Discharge’- In line validation – Modifying a medication
from hospital to home
Prior to admission
Admission
Review/Transfer

57. ‘Discharge ’- Discharge Prescription

58. 4. Communication with community
providers

59. ‘Pharmacy and Physician coordinates’
Prior to admission
Admission
Review/Transfer

60. Physician coordinates data flow
Patient consent
Retrieve physician identity from
RAMQ for scrambled physician
license number
Retrieves scrambled physician
license number from RAMQ
along with medication list
Discharge prescription
Fax changes to
prescribing physicians in the
community
MOXXI
servers
RAMQ
Database
RightRx
servers
Link with College of
Physicians file to
retrieve physician
coordinates PHIRE
Database
CMQ file

61. Pharmacy fax number data flow
Patient consent
Retrieves medication and
pharmacy coordinates from
RAMQ but missing fax number
Discharge prescription
Fax changes to
community pharmacies
MOXXI
servers
RAMQ
Database
RightRx
servers
Link with Order of
Pharmacist’s (OPQ) file
to retrieve pharmacy fax
number
PHIRE
Database
CMQ file
Match RAMQ
pharmacy coordinates
with OPQ file

62. Issues discovered along the way:
1. Social ethical issues:
• Consent-in vs. Opt-out for accessing community drug data
• The incompetent patient
• Refusal to consent and consequences for treatment
2. System Issues:
• Idiosyncratic process unit by unit, service by service

63. 3. Professional:
• Roles of physicians and pharmacists in MedRec
• Documentation of pharmacy recommendations for
physician’s orders
• Prescribing medications where indication is not known
and decision to modify was made by someone else
• Expanding role of pharmacy technicians

64. 4. Technical Issues:
• Lack of standardization of hospital Drug Information
systems (DISs)
• Lack of posology in prescription claims data
• Knowledge base and process used to match community
and hospital medications
• Customized concoctions

65. robyn.tamblyn@mcgill.ca
Thank you!

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Coming Soon
• Canadian Patient Safety Week is October
28 to November 1, 2013. Register now at
http://www.patientsafetyinstitute.ca
• Visit us at the Zoomer Show in Toronto
on October 26 & 27 (Direct Energy
Building, Exhibition Place). We are in
booth 3225.
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Coming Soon (Fall 2013)
• Tool kit to help teams move from paper-based
to electronic MedRec system.
• PSEP module on Medication Reconciliation
• CCEP certified eLearning module on Medication
Reconciliation at admission to Acute Care
• TechTalk article on the Pharmacy Technician's
role in Medication Reconciliation
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68. www.saferhealthcarenow.ca
Canadian MedRec Quality Audit month.
68
• Join us for a national webinar on October 1, 2013 at 12
noon ET to kick-off the Canadian MedRec Quality Audit
month.
• Register Now to participate in the Canadian MedRec
Quality Audit month (October 1 – 30, 2013). Please note:
Both registration and participation are complimentary.
A tally of audits will be unveiled at Canada’s Virtual Forum on
Wednesday, October 30th , a day dedicated to medication safety
across the continuum.

69. www.saferhealthcarenow.ca69
We encourage you to report
medication incidents
Practitioner Reporting
https://www.ismp-canada.org/err_report.htm
Consumer Reporting
www.safemedicationuse.ca/

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We want to hear from you one more time
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