Medication Reconciliation Technology to Improve Quality of Transitional Care (MedMatch)

• Reconciliation of outpatient medications [ Time Frame: Hospital admission, transfer, and discharge; 1 year ] [ Designated as safety issue: Yes ]
  Number and fraction of outpatient medications prescribed or addressed as to why prescribing did not occur. Number and fraction of cases with MR by a pharmacist. Number and fraction of cases undergoing any MR. Number and fraction of cases where any outpatient medications were not prescribed or addressed as to why prescribing did not occur.
  
  

• Measurement of potential for harm and potential severity of harm [ Time Frame: Hospital discharge; 1 year ] [ Designated as safety issue: Yes ]
  For each medication discrepancy, the study team will reach consensus about potential for harm and potential severity of harm. The study team will adopt the following framework: little or no confidence (e.g., omission of multivitamin); slight to modest confidence (e.g., docusate 200 mg every morning, instead of 100 mg twice daily); less than 50% chance but close call (e.g., omission of as-needed enema at discharge); more than 50% chance but close call (e.g., omission of fluticasone twice daily at discharge); or strong confidence (e.g., omission of as-needed haloperidol).
  
  
• Measurement and analysis of providers' perspectives [ Time Frame: Start and end of trial; 1 year ] [ Designated as safety issue: No ]
  We will conduct a before-and-after survey of providers. Providers will be surveyed about satisfaction with care, managing medications, and usefulness of local information systems in managing medications.
  
  
• Measurement and analysis of patients' perspectives [ Time Frame: Hospital discharge; 1 year ] [ Designated as safety issue: No ]
  The inpatient geriatrics consultation service has begun calling patients who received geriatrics consultation and were subsequently discharged to home. The calls are made by telephone within 72 hours of discharge. Patients are asked eight to ten questions, addressing satisfaction with care, receipt of information about medications, and adherence to medications.
  
  
• Reportable financial and organizational dimensions [ Time Frame: Start of trial; time 0 and 1 year ] [ Designated as safety issue: No ]
  We will track and report hours required for several parts of the development and implementation, as follows: hours required for new technical development; and hours providers spend in learning about system and how to use it.
  
  
• Utilization of intervention [ Time Frame: Hospital admission, transfer, and discharge; 1 year ] [ Designated as safety issue: No ]
  Fraction of intervention admissions for which Web-based medication list was reviewed or modified. Mean duration of use of Web-based application. Fraction of intervention admissions, transfers, and discharges for which new medication list was used to order medications. Fraction of medications on medication list that were ordered on admission, transfer, and discharge. Timing of when medication reconciliation occurred.
  
  
• Measurement and analysis of drug-related medical errors [ Time Frame: Hospital discharge; 1 year ] [ Designated as safety issue: Yes ]
  At discharge, we will assess for unintentional medication discrepancies at discharge. At ambulatory followup, we will assess whether the medications should have been prescribed at discharge. When a patient is discharged from the hospital and resumes ambulatory care, the patient is expected to adhere to the discharge prescriptions. Each discharge will be reviewed by members of the study team, to determine, for each medication listed on the pre-admission medication list but not prescribed at discharge, whether the discrepancy was intentional or unintentional.
  
  
• Measurement of adverse drug events and near misses [ Time Frame: Hospital discharge; 1 year ] [ Designated as safety issue: Yes ]
  We will count deaths and will identify and assess adverse drug events (ADEs). The following kinds of triggers will be used to identify encounters that might reflect ADEs: diagnostic codes for diagnoses associated with ADEs, potential ADEs, or medication errors; use of specific drugs suggesting that an ADE may have occurred; potentially dangerous drug combinations; combinations of drugs and symptoms (e.g., angiotensin converting enzyme inhibitor and cough); combinations of diagnoses and drugs; and combinations of drugs and miscellaneous.
  
  
• Medication discrepancies between pre-admission and ambulatory followup [ Time Frame: Ambulatory followup; 18 months ] [ Designated as safety issue: Yes ]
  Mean number of erroneous discrepancies between pre-admission and ambulatory followup
  
  

This project will test a systems-based intervention of the electronic medical records system. The specific aims of this study are to integrate a new electronic medication reconciliation (MR) system with an electronic prescribing system, conduct a randomized controlled trial of MR, and determine whether electronic facilitation of MR alters MR and the incidence of medication errors in ambulatory care. On a patient's hospital admission, a new Web-based MR module will receive an automatically compiled outpatient medication list. Following discussion with the patient, medical personnel will update the list, which will then be delivered to the computer-based provider order entry system and become actionable for prescribing. Main outcomes include adverse drug events and erroneous discrepancies between the pre-admission medication list and the medication list upon the patient's return to ambulatory care. We hypothesize that electronic facilitation of inpatient MR will improve completion of MR and will decrease the incidence of drug-related medical errors.