Medication Reconciliation

Medication documentation is about how medication decisions are recorded, communicated, validated, implemented, supported and followed. It promotes safe, effective and appropriate drug therapy as part of patient-centred care. The Connect Care "Medication List" is a record of medications in active use by a given patient at a given time.

Encounter-level Medication Reconciliation

The collection of the best possible medication history (BPMH) occurs in both outpatient and inpatient workflows. Reconciliation of pre-encounter medication use with ongoing and new medication use during an encounter occurs at care transitions (e.g., admission, discharge, transfer). The goal is clear documentation of what a patient should be taking, with explanation of any variance between intended and actual medication use.

Home-to-Facility (Admission) Reconciliation

A BPMH is needed when patients present to a Connect Care encounter from a setting (e.g., home or facility) not using the Connect Care clinical information system. The BPMH outcome will be a new or updated list of "home" medications.

Facility-toHome (Discharge) Reconciliation

Discharge medication reconciliation must occur whenever a patient is released from a facility where Connect Care is the record of care. This is a simple, quick and easy activity if a medication review and reconciliation was done at admission. Clinicians use the discharge orders section of the discharge navigator to indicate which home medications to continue and which new or changed inpatient medications to prescribe.

All medications that a patient is expected to take must be entered to Connect Care, including any medications newly prescribed at discharge. This ensures that community pharmacy reports, after visit summaries and Connect Care outpatient medication records are accurate. Consistent discharge medication management is a major preventive for medication errors and iatrogenic harm.

Facility-to-Facility Reconciliation

When patients present from facilities also using Connect Care (e.g., patient sent from a long term care facility to an emergency department for assessment), their facility medication list takes the place of a home medication list. In these cases, there is no need to re-build the medication list through a BPMH process. A home medication list should not be populated. Medication reconciliation involves deciding which pre-encounter facility medications should be continued, held or stopped when the patient is admitted to the new facility.

To make this straightforward, the usual Home Medications navigator sections are hidden for Connect Care long term care patients presenting to Connect Care emergency departments. Instead, the pre-encounter facility medications are displayed and a link is provided to a navigator facilitating the selective re-ordering of pre-encounter facility medications.

Event-level Medication Reconciliation

Identifying and accounting for differences between outpatient (home) and encounter (admission, discharge, transfer, etc.) medication use is a minimum use norm expectation. Reconciliation is also important when certain major events (e.g., surgical intervention, critical care) occur within an encounter. If encounter-level medication review has already been done, then event-level review is easy to fit into pre-op, post-op and transfer workflows.

System-level (outside) Medication Reconciliation

The clinical information system (CIS) has interfaces to external digital health records, including legacy non-Connect Care CISs (e.g., Metavision, Meditech, eCLINICIAN) and the Alberta NetCare Portal electronic health record. Connect Care users may be alerted to medication information appearing in these external systems, sometimes with the ability to import data into the Connect Care Medication List as part of medication reconciliation workflows.

The presence of outside information that might be reviewable or importable is indicated with an "e" (Care Everywhere) icon appearing at the top right of the patient storyboard in a patient chart open in Hyperspace. Clicking on this opens a "Reconcile Outside Info" chart activity where allergy, medication, problem list or immunization data from external systems may appear. Medication data from eCLINICIAN and other legacy CISs can usually be imported, sparing the need to re-type medication details.

An early interface to the Pharmacy Information Network proved premature and is retired until more a more reliable interface can be deployed. Some stray PIN outside reconciliation notices may remain, but can be easily removed: