1. Connecting across the continuum of care Melinda Muller MD FACP Legacy Health System Portland Oregon mmuller@lhs.org

2. Support This project funded under grant number 5U18HS015904-02 from the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services. The opinions expressed are those of the authors and do not reflect the official position of AHRQ or the U.S. Department of Health and Human Services. This project funded under grant number 5U18HS015904-02 from the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services. The opinions expressed are those of the authors and do not reflect the official position of AHRQ or the U.S. Department of Health and Human Services.

3. Legacy Health System: Who Are We? 5 hospitals: 5 hospitals: –4 in Portland Oregon –1 in Vancouver Washington 11 Primary Care Clinics 11 Primary Care Clinics Multispecialty Surgical Clinics Multispecialty Surgical Clinics Level 1 Trauma Center Level 1 Trauma Center Oregon Burn Center Oregon Burn Center Rehabilitation Institute of Oregon Rehabilitation Institute of Oregon

4. Legacy’s hospital reconciliation process Utilizes EMR Utilizes EMR –Clinics utilize EMR medication module already Admission/Transfer: Admission/Transfer: –RN obtains list including medication/dose/sig and allergies and enters into the EMR –Paper home medication list ready for physician to review –MD reconciles home list with hospital orders

5. Hospital process continued Discharge: Discharge: –MD reconciles home meds with discharge meds in the EMR –Prints/faxes prescriptions –RN reviews list with patient & gives to patient –Copy of medication list sent to PCP/next provider of care

6. Medication Module

7. Home Medication List

8. Clinic process Current list is printed from EMR & given to patient in waiting room to review Current list is printed from EMR & given to patient in waiting room to review Patient reviews with provider during visit Patient reviews with provider during visit Changes/updates are made & reviewed with patient Changes/updates are made & reviewed with patient Patient leaves with an updated list Patient leaves with an updated list Documentation of review noted in EMR Documentation of review noted in EMR

9. Connecting across the continuum Same medication module used inpatient & outpatient Same medication module used inpatient & outpatient –Medication list already partially built at admission –Easy access to inpatient changes when patient comes in for follow up –Able to view what patient has been on in the past –Nonemployed physicians can view through the hospital portal

10. Difficulties TIME – perceived as add on work for everyone TIME – perceived as add on work for everyone Competing demands Competing demands –Patient care –Other initiatives Patient understanding/knowledge Patient understanding/knowledge Differing interpretations of medication adherence (not taking vs not taking today) Differing interpretations of medication adherence (not taking vs not taking today)

11. Other issues Not all hospital departments utilize EMR Not all hospital departments utilize EMR New process revealed existing workflow problems & was expected to fix them New process revealed existing workflow problems & was expected to fix them IR stretched thin – maintaining 2 EMRs IR stretched thin – maintaining 2 EMRs

12. Compliance

13. Successes Medication discrepancies statistically reduced Medication discrepancies statistically reduced Improvement in adverse drug event rates Improvement in adverse drug event rates Patients satisfied with product Patients satisfied with product More integrated care overall More integrated care overall Being integrated into the culture Being integrated into the culture