Another Chance to Get Our Patients’ Medication Lists Right

Fairly recently, our electronic health record (EHR) added yet another feature, a system of checks and balances that happen in the form of a “soft stop” at the time of closing the office encounter.

Essentially, this is a reminder to the provider that a patient has marked certain medications on their list for discontinuation or alteration. Once we’ve finished our notes, and put in all the appropriate billing codes, we go to finalize the encounter, and we are reminded that the patient has acted on these medications in their chart, through the portal, and it’s recommended that we pay attention to this data.

I actually really love this feature, because I often find that patients have marked a medicine as discontinued, or that they changed how they are taking it, even if during the course of our office visit we have just confirmed that the patient is taking all their medications and that “nothing has changed.”

Even when we go through them one by one, methodically cleaning up the list and getting rid of duplicates and old doses from other providers, expired medicines and short courses of antibiotics they took, a one-time trial of something for their blood pressure or cholesterol that they ended up never taking, patients will often confirm that they’re taking a medicine that we later discover they’ve marked for discontinuation.

This often feels like an extra bonus, a final clean sweep that lets me — with even more assurance than I’ve had from talking to the patient — confirm that our medication list is accurate and up-to-date.

Over the years, keeping an accurate medication list has always been an incredibly frustrating process, for us as we see our patients, and probably for all our patients as well. As patients move from provider to provider within our institution, and also see providers outside of our institution, medications are often added and subtracted, sometimes with little relation to the actual truth of the matter.

When we first enter our patient’s charts and look at their medication list, there is often a highlighted notation that says, “Reconcile outside medications.” This can sometimes be quite helpful, sending a hint of a recent illness that took someone to an urgent care center for which they were prescribed a couple of medicines, and sometimes a whole new medical condition that you aren’t even aware the patient had, such as when we discover a few psychiatric medicines on their list that they neglected to tell us about.

This often opens up a whole bunch of interesting conversations, such as the terrible low back pain that sent them to the emergency room last month that they forgot about, or significant worsening of depression that they hadn’t opened up to us about, not feeling quite ready to share.

Maintaining an accurate medication list within our electric electronic medical record has often been problematic, as multiple providers have multiple ways of keeping a medication list updated, often times with many different people through the course of an encounter touching and changing a list. Duplicate medications will be added, doses will be adjusted without discontinuing the prior doses, and sometimes a medicine will be added without stopping the one that it was meant to replace.

Everyone is pretty free and loose about clicking that confirmation button that assures everyone that they’ve gone through the medication list line by line, medication by medication, and that it is 100% accurate. But we’ve all seen this done when we know that it is certainly not true, and we’re all guilty of having done it ourselves.

In the old days (not so long ago) when our emergency department did not use the same electronic medical record that we do, we would often read their notes, which came to us as downloaded summaries at the end of the visit, and a list of the patient’s current outpatient medicines would be included.

Unfortunately, this often simply represented the last list they had on file for the patient, which was usually from their last admission through the emergency room.

Antibiotic, oral steroid, albuterol inhaler. Pain medication, diuretic, refill of a blood pressure medication.

We all know it takes an enormous amount of time to go through all of a patient’s medicines, when there are many other issues that need to be attended to during our too short visits. Far too often, like many things in medicine, asking “has anything changed?” is not going to get you accurate data, and could potentially lead to a great deal of harm.

And we’ve also seen other variations of this, such as when patients have no idea what they’re taking, and tell us that “some other doctor started me on some medicine for that problem I saw them for; I think was a little white pill,” and we’re left in the uncomfortable position of trying to figure out what specific medication and dose to add to their medication list. “Little white pill.” Orally? How many times a day?

Ideally, as all our systems begin to communicate more, we will be able to get a more accurate and real-time picture of what a patient is actually taking, comparing what we think they are on and what’s actually being ingested into their bodies.

Real-time data from the patient’s medication bottles, chip trackers that see what pills patients are taking to track compliance, and the use of online tools that allow patients to tell us what medicines they’re taking and help them manage their medications, will someday be part of our armamentarium.

But for now, getting that gentle reminder (gentle, although it is highlighted in yellow) at the time of closing the office encounter note can go a long way to helping us know what our patients are truly taking, to help them get the best care.

To get one more thing right.

Fred N. Pelzman, MD, of Weill Cornell Internal Medicine Associates and weekly blogger for MedPage Today, follows what’s going on in the world of primary care medicine from the perspective of his own practice.