Department of Family Medicine Implementation of a Ambulatory Medication Reconciliation Process Utilizing Non-physican Staff William Jih, M.D. Medical Director Department of Family Medicine Loma Linda University

Background Academic Faculty Practice 18 faculty physicians 3 Mid-level faculty practitioners Approximately 60K patient visits per year Implemented Electronic Medical Record in 2006

Background EMR was supposed to be “easier” and “safer” Reality was that the EMR created more steps and more work that wasn’t previously done. Created more confusion and frustration Electronic Medication lists were confusing. More options for medication “Actions”

Goals Reduction in Medication List errors to improve Patient Safety Errors resulting in Harm: >1.5 million/year Deaths: 7,000/year Cost: $3.5 billion/year Balance the workload Working at the top of their license Toyota Lean “Kaizan”

Process implementation using Medical Assistants in Medication Reconciliation Phase 1 “Creating a culture” Trained M.A. on how to conduct a Medication History Used a printout of the Electronic Medication List Still relied on Clinicians to reconcile the list electronically Phase 2 Trained M.A. staff to delete and complete medications electronically and cue refills Trained M.A. staff to add in by history medications not on the list Eliminated paper printouts / implemented communication sheet as a replacement

Methods Audited Patient Charts after office visit Classified 6 types of errors Duplicates Class redundancy Outdated Medications Discrepancy with Documentation Antibiotics not discontinued Acute Medications (prn) Audited at Baseline and after each phase

Exclusion Criteria Excluded patients <25 Less likely to have Chronic Medications Excluded any medication from review prescribed after the office visit Phone refill, eRx etc… Excluded any medication list changes made by other practices/specialties after the office visit

Results # Charts reviewed # Charts with errors % Charts with errors # Charts correct % Charts Correct Baseline 91 72 79.12 19 20.08 Phase 1 185 132 71.35 53 28.64 Phase 2 247 36.84 156 63.15

Discussion Culture Challenges Balancing the work load Staff Buy-in Clinician Buy-in Balancing the work load Shifting work across the different areas

Discussion Knowledge deficit Physician putting up barriers Confusion about how to interpret errors Physician putting up barriers

Future Steps Sustaining Change Queuing up refills Spread to other institutional clinics

Acknowledgements Resident Researchers Research Director Albert Mu, D.O. Heidi Choi, M.D. Research Director Kelly Morton, Ph.D. Staff Leadership Garcia Troy, R.N. Christina Meza, L.V.N. Corrine Castro, L.V.N. Jamie Martin, L.V.N.