Questions of medication reconciliation in VistA.

[Kevin Toppenberg]

I have questions about how medication reconciliation is supposed to work in VistA.   Just so that we are on the same page, below is a brief description of how the medication cycle works in an outpatient practice. 

1. Patient presents to the office on a list of medications.  For my example, let's pretend they are taking lisinopril 10 mg (a blood pressure medication)
   
2. Nurse takes a medication history, and updates our records to match what the patient is taking.  (This is called "medication reconciliation").  This list will be called the pre-visit med list.
   
3. Doctor sees patient and determines the dose of lisinopril needs to be increased to 20 mg, write a new prescription
   
4. Ideally this new prescription is captured in VistA, such that there is an accurate post-visit medication list. 
   
5. Patient goes home.  At this point any number of things can happen: they get the new lisinopril 20 mg as directed, or they might continue using their prior lisinopril 10 mg, or they might not take it at all.  Or they might go see another doctor that changes them to lisinopril 40 mg.  Numerous other confusing variances are common. 
6. Patient returns to office for next visit, and the cycle repeats, starting back at step 1.

In my office, we don't use the medication tab in CPRS because we don't have integrated prescribing.  Instead we prescribe in a web page (Allscripts) and then maintain a free-text medication list in a manner that can be carried forward to new notes via TIU Text Objects.    In our progress notes, we have include the pre-visit med list, and then at the end of the note, the post-visit medication list.   I am working to pull back information from the web page and am wondering how to use VistA's features if possible.  

It seems to me that VistA (or at least as I seen in CPRS), doesn't have the ability to have a pre and post medication list.  Instead, it just has a record of what has been prescribed in VistA.   I have some patients that see me in the private sector, and ALSO see a VA doctor from time to time, to keep up their eligible status.  So medications that I write will not be in the VA's VistA system.  

Question

-- When a patient enters the VA system, how do they manage this.  I think I have seen that there is an "outside meds" area, but these are all free text and thus not available for drug-interaction testing.

-- Are there any dialogs or standard method in CPRS for medication reconciliation?

-- How would VistA handle telling a patient to stop a medication?  Stop it on the medication tab?  And what if they keep taking it anyway from home supply?

Thanks

Kevin

[ivaldes]

This is a chronic problem. It is a problem because you can only exhort or educate the patient and what they do in their house is anyone's guess. At least with Astronaut, it writes back to VistA when the eRX window is closed and reflects the status accurately Active, Inactive, etc. A big however, is that the Surescripts protocol does have the ability to cancel but very few pharmacies actually support it. This makes it very difficult to cancel orders placed with pharmacies such as spending 30 minutes on the phone. This problem was noted in a recent JAMA editorial. 

[Sam Habiel]

Kevin,

You ask the hard questions.

1. Non-VA meds are coded medications. They are NOT free text.

2. Yes. There is a health summary component and TIU Object used for Medication Reconciliation with this very name. A bit of googling the VDL and you should find it. If we have a nurse from the VA, he/she will tell you how it's used in real life.

3. Aren't patients annoying? Can't we chain them to a pole and watch their every move? How about keeping them as pets? This way we can make sure they take the medication we want them to. Dammit! I am the doctor! Who do they think they are?

--Sam

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[Matt King]

Kevin,

There are  many ways to approach this problem and most of them involve a lot of work. I would probably go with this low tech, easy approach:

1) Make a Pharmacy Medication entry called Reported Home Medication (or something similar). It doesn't need to be linked to an NDF entry. Turn off the duplicate medication alert. I'm pretty sure you are using the FDB alerts by now.

2) Make a TIU object for non-VA meds.

3) Make your object from the Allscripts page that can be imported into a Note

4) Make a note title called Medication Reconciliation and place your two objects onto that note with some boilerplate language: Here is the medication list pre-visit (Non-Va med object); Here is the medication list post-visit (Allscripts object)

5) You might want to change the name of Non-VA Medications to Home Medications or something similar.

When the nurses are getting the medication home list from the patient, have them use the non-VA "Reported Home Medication" entry over and over again and put the real med name in the comments section or better yet, in the "dosage" field, which will also accept free text.

The last thing you do after prescribing the medications is you or the nurse open the Med Rec note and edit it and sign. (Sometimes you may need to add meds from the Home meds that you aren't actually prescribing to the post med list.

You can also add a section between the two objects describing why the two lists don't match (increased Lisinopril to control pressure better; dc-ed ampicillin no longer needed, etc.)

matt

On Thursday, August 24, 2017 at 9:05:03 AM UTC-4, Sam Habiel wrote:

Kevin,

You ask the hard questions.

1. Non-VA meds are coded medications. They are NOT free text.

2. Yes. There is a health summary component and TIU Object used for Medication Reconciliation with this very name. A bit of googling the VDL and you should find it. If we have a nurse from the VA, he/she will tell you how it's used in real life.

3. Aren't patients annoying? Can't we chain them to a pole and watch their every move? How about keeping them as pets? This way we can make sure they take the medication we want them to. Dammit! I am the doctor! Who do they think they are?

--Sam

On Wed, Aug 23, 2017 at 2:06 PM, ivaldes <ival...@gmail.com> wrote:

This is a chronic problem. It is a problem because you can only exhort or educate the patient and what they do in their house is anyone's guess. At least with Astronaut, it writes back to VistA when the eRX window is closed and reflects the status accurately Active, Inactive, etc. A big however, is that the Surescripts protocol does have the ability to cancel but very few pharmacies actually support it. This makes it very difficult to cancel orders placed with pharmacies such as spending 30 minutes on the phone. This problem was noted in a recent JAMA editorial. 

On Wednesday, August 23, 2017 at 9:47:58 AM UTC-5, Kevin Toppenberg wrote:

-- How would VistA handle telling a patient to stop a medication?  Stop it on the medication tab?  And what if they keep taking it anyway from home supply?

Thanks

Kevin

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[Kevin Toppenberg]

Sam,

I know you are joking, but just to clarify....  I understand that patients are free agents and will take what they think is best.  There are times when I am glad that patients stop a medication when it is not acting as expected.  My great frustration, however, is when I don't know what is going on.  When a patient tells me that they are taking "everything the same" as last visit.  And they don't bring in their medications so I am having to operate in the dark.  We put up signs everywhere and threaten to not see patients if they don't bring in their meds for review -- but it is a never-ending battle.    So the point is that 1) we need medication reconciliation, and 2), such reconciliation is difficult.  

I don't quite understand your solution.  Both a health summary and a TIU object are methods for reading information OUT of the database, not to put reconciliation information INTO the database.  

Thanks

Kevin

On Thursday, August 24, 2017 at 9:05:03 AM UTC-4, Sam Habiel wrote:

Kevin,

You ask the hard questions.

1. Non-VA meds are coded medications. They are NOT free text.

2. Yes. There is a health summary component and TIU Object used for Medication Reconciliation with this very name. A bit of googling the VDL and you should find it. If we have a nurse from the VA, he/she will tell you how it's used in real life.

3. Aren't patients annoying? Can't we chain them to a pole and watch their every move? How about keeping them as pets? This way we can make sure they take the medication we want them to. Dammit! I am the doctor! Who do they think they are?

--Sam

On Wed, Aug 23, 2017 at 2:06 PM, ivaldes <ival...@gmail.com> wrote:

This is a chronic problem. It is a problem because you can only exhort or educate the patient and what they do in their house is anyone's guess. At least with Astronaut, it writes back to VistA when the eRX window is closed and reflects the status accurately Active, Inactive, etc. A big however, is that the Surescripts protocol does have the ability to cancel but very few pharmacies actually support it. This makes it very difficult to cancel orders placed with pharmacies such as spending 30 minutes on the phone. This problem was noted in a recent JAMA editorial. 

On Wednesday, August 23, 2017 at 9:47:58 AM UTC-5, Kevin Toppenberg wrote:

-- How would VistA handle telling a patient to stop a medication?  Stop it on the medication tab?  And what if they keep taking it anyway from home supply?

Thanks

Kevin

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[Kevin Toppenberg]

Matt,

Thanks for your reply.  I don't quite understand everything that you are saying.  But it is OK.  I was mostly wondering how the flow was in a VA hospital.  Do you know what they are doing at your non-VA site?

Kevin

[Matt King]

Kevin,

My not sure how the VA does it, so my apologies. At my site, we think of medication reconciliation as 2 lists side by side:

The first list is what the patient is taking before you see them, the pre-visit (or Home) medication list. This includes OTC, herbals, supplements, and meds prescribed from other physicians. These all can be captured in the non-VA meds section

The second list is what they are taking after you see them (or should be taking after you see them). This also includes OTC, supplements, herbals and meds prescribed from other physicians.

Then you must "reconcile" why these two lists are not identical. This reconciliation can be a little narrative in between the two lists:

Increased Lisinopril from 10 to 20 because pressure remains high. Discontinued HCTZ, hypokalemia. You can also "reconcile" by adding something in the comments sections of the medication entries at the time of entry: "Will d/c because it is not working." These 2 methods of reconciliation are not mutually exclusive.

I find this process easiest to record and complete by using 2 med objects brought into the same note after the pre-visit meds are properly recorded and after the new meds are prescribed. I open the Med Rec and the lists magically appear. Then all I need to do is add the reconcile part. Also, if there are medications/OTCs/Supplements etc on the pre-visit list that aren't included in the post-visit list, I can just copy and paste them from the pre-visit section into the post visit section.

[Kevin Toppenberg]

See below 

On Tuesday, August 29, 2017 at 12:04:12 PM UTC-4, Matt King wrote:

Kevin,

My not sure how the VA does it, so my apologies. At my site, we think of medication reconciliation as 2 lists side by side:

The first list is what the patient is taking before you see them, the pre-visit (or Home) medication list. This includes OTC, herbals, supplements, and meds prescribed from other physicians. These all can be captured in the non-VA meds section

The second list is what they are taking after you see them (or should be taking after you see them). This also includes OTC, supplements, herbals and meds prescribed from other physicians.

Then you must "reconcile" why these two lists are not identical. This reconciliation can be a little narrative in between the two lists:

Increased Lisinopril from 10 to 20 because pressure remains high. Discontinued HCTZ, hypokalemia. You can also "reconcile" by adding something in the comments sections of the medication entries at the time of entry: "Will d/c because it is not working." These 2 methods of reconciliation are not mutually exclusive.

I find this process easiest to record and complete by using 2 med objects brought into the same note after the pre-visit meds are properly recorded and after the new meds are prescribed. I open the Med Rec and the lists magically appear. Then all I need to do is add the reconcile part. Also, if there are medications/OTCs/Supplements etc on the pre-visit list that aren't included in the post-visit list, I can just copy and paste them from the pre-visit section into the post visit section.

Getting closer, but still not following you entire.  When you have someone record the pre-visit meds, where are you putting them?  Into VistA via the medication tab?

Then, if during a visit you prescribe different medications in VistA, do you then bring in another TIU TEXT OBJECT containing the meds AFTER you re done prescribing?

When you say you "open the Med Rec and the two lists magically appear", I don't understand this.  Is "Med Rec" a note template type?  A dialog in CPRS?

Thanks

Kevin

[Matt King]

see below

On Wednesday, August 30, 2017 at 3:32:22 PM UTC-4, Kevin Toppenberg wrote:

See below 

On Tuesday, August 29, 2017 at 12:04:12 PM UTC-4, Matt King wrote:

Kevin,

My not sure how the VA does it, so my apologies. At my site, we think of medication reconciliation as 2 lists side by side:

The first list is what the patient is taking before you see them, the pre-visit (or Home) medication list. This includes OTC, herbals, supplements, and meds prescribed from other physicians. These all can be captured in the non-VA meds section

The second list is what they are taking after you see them (or should be taking after you see them). This also includes OTC, supplements, herbals and meds prescribed from other physicians.

Then you must "reconcile" why these two lists are not identical. This reconciliation can be a little narrative in between the two lists:

Increased Lisinopril from 10 to 20 because pressure remains high. Discontinued HCTZ, hypokalemia. You can also "reconcile" by adding something in the comments sections of the medication entries at the time of entry: "Will d/c because it is not working." These 2 methods of reconciliation are not mutually exclusive.

I find this process easiest to record and complete by using 2 med objects brought into the same note after the pre-visit meds are properly recorded and after the new meds are prescribed. I open the Med Rec and the lists magically appear. Then all I need to do is add the reconcile part. Also, if there are medications/OTCs/Supplements etc on the pre-visit list that aren't included in the post-visit list, I can just copy and paste them from the pre-visit section into the post visit section.

Getting closer, but still not following you entire.  When you have someone record the pre-visit meds, where are you putting them?  Into VistA via the medication tab? You use the non-VA meds on the orders tab. If you can't see a non-VA mediation ordering entry on your orders tab, you will need to add it. It is called "PSH OERR". You also need to make a Pharmacy Med entry called Reported Patient Medication, or something similar and make it available on the non-VA med list. This is so you have a place to record the meds/supplements/herbals without needing to create a pharmacy entry for each possible thing your patient may be on. This means the medications entered this way will not be checked for interactions against the other meds you prescribe. But since you are prescribing using allscripts software, they wouldn't be checked anyway, even if you matched every drug entry properly.

Then, if during a visit you prescribe different medications in VistA, do you then bring in another TIU TEXT OBJECT containing the meds AFTER you re done prescribing? Here, I'm proposing you figure out how to create an object from the allscripts prescription list that can be put into a note. Or just copy and paste the list directly into the note.

When you say you "open the Med Rec and the two lists magically appear", I don't understand this.  Is "Med Rec" a note template type?  A dialog in CPRS? I'm saying create a TIU Note title called Medication Reconciliation with both objects (one from the non-VA meds list and the other from the allscripts list) embedded. If you open that note title after the other work is done (nonVA meds added, new meds prescribed), they will automatically be available in the note. Of course, we don't use allscripts, but prescribe directly from VistA, so that second object would not be a problem for us. Alternatively, you could embed this into a CPRS template and then be able to include it into your main note.

 

We don't use this method that I just described at CRH, but I think it is the easiest way to solve Med REC in VistA. I know that the VA did some work on Med Rec and have some objects and other items which I think ended up on the reports tab, but I never really explored their solution. I'm sure you could find something on the VDL. -Matt

[Kevin Toppenberg]

Thanks Matt,

I've gotten side tracked into a different project.  When I get back to this, I'll post more.

Thanks again

Kevin