Our first set of project goals focused on the design and construction of i) a user interface to facilitate the building of the PAML, called the PAML Builder; ii) a repository for storing information collected through the PAML Builder; iii) services to mediate access to the repository; and iv) a relational data-mart to support the analytical and reporting needs of this project.
After iterative rounds of design, construction, usability testing, and functional testing, we released our first solution set in November 2005.
Invoking the Pre-Admission Medication List (PAML) Builder
Our clinical leaders determined that, in most cases, the admitting clinician—often a member of the housestaff but perhaps a nurse practitioner or a physician assistant—would be primarily responsible for the construction of the PAML for each patient. To facilitate this process, the PAML Builder was designed as a browser-based application so that it could be invoked by the admitting clinician from multiple points in his or her workflow during the patient’s admission process. For example, the PAML Builder can be invoked i) as a stand-alone application on the Windows Desktop before the clinician has invoked the CPOE application; or ii) as an application embedded within the CPOE application while the clinician is writing, reviewing or renewing orders. illustrates two examples of how the PAML Builder can be invoked.
The PAML Builder
A and B illustrate the appearance of the PAML Builder for a sample patient. The application is organized into three columns. The left column contains the ‘medication source list’ (MSL), which lists medication information from multiple data sources that may inform the user about what the patient was taking before admission. The middle column contains action buttons that allow the user to use information on the MSL to build the PAML, and the right column houses the PAML for the patient.
(A) PAML Builder application: Patient with outpatient medication information residing in two electronic sources. (B). PAML Builder application: PAML being constructed by admitting clinician.
Medication Source List (MSL)
The medication source list (MSL), labeled ‘Meds from Electronic Sources,’ aggregates medication information that resides in four electronic sources: the current medication lists from the two outpatient EMRs and the most recent discharge medication orders stored within the two CPOE systems. Each medication is tagged with the date at which the data were last updated. For medications on the outpatient medication lists, that date corresponds to the date the medication was last reviewed by a physician or the date the last prescription was generated; for medications on discharge orders, that date corresponds to the date of the patient’s previous discharge.
Since the four medication sources may contain repetitive information, we organize the list to facilitate review by the user. However, the different medication terminology systems used by each data source make this organization challenging. As a first step toward displaying information from multiple non-interoperable sources, we use empirically developed text-based heuristics to attempt to group medications together by the generic name. This grouping is accomplished, where possible, by first mapping each medication back to its generic name using its native medication dictionary. We then strip certain strings off the name of each medication so that only the principal ingredient of the medication (the ‘core’ generic name) remains. Last, all the medications from the four sources are sorted by their corresponding ‘core’ generic names and medications with common ‘core’ generic names are listed together under the same generic name. For example, prescriptions for ‘Zestril,’ ‘Prinivil,’ and ‘lisinopril HCl’ from different sources are listed together under the generic name ‘lisinopril.’ We recognized early during the project that heuristic matching of the ‘core’ generic names might occasionally cause medications to be misgrouped. We employed three approaches to mitigate this risk. First, we made the explicit decision not to hide medication entries even if they were grouped under the same ‘core’ generic name, so that clinicians could still decide whether all the medications listed under each group referred to the same medication the patient had actually been taking in the outpatient setting or represented separate medication orders. For example, a diabetic patient with the two entries ‘NPH insulin 40u SC qam’ and ‘NPH insulin 20u SC qhs’ from the outpatient EMR would have both entries grouped under ‘NPH insulin’ on the MSL, but because both entries would be visible in the MSL, clinicians would be prompted to consider both entries as active entries. Second, we recruited clinicians to review matched medication lists on 100 real patients to ensure that our matching algorithm would not cause any confusion. Third, on-site trainers monitored the use of the MSL closely during our pilots. To accommodate the usual workflow of medication history-taking, we encourage the users of the PAML Builder to print the MSL before they start interviewing the patient and to use the MSL as a starting point to collect medication history from the patient. The application also allows users to review outpatient progress notes and discharge summaries of the patient, as users may want to understand the rationale behind the medication regimen or to uncover medications that are not included on the MSL.
Building the Pre-Admission Medication List (PAML)
Once the clinician responsible for building the PAML has collected the necessary information, she or he can use the application to do so electronically. If a medication a patient has been taking before admission appears on the MSL, the responsible clinician has two ways to build the corresponding entry on the PAML. If no changes in dose, strength/form, and frequency are necessary, the clinician moves the medication from MSL into the PAML without changes. If changes are required, the user specifies that an entry from the MSL should be moved to the PAML with modifications, and the user interface then prompts the user to enter the appropriate dose and frequency for the medication. If a medication a patient has been taking does not appear on the MSL, the user can build an entry on the PAML de novo by specifying the medication name, route, dose, and frequency of the medication. Since the dose and frequency information may not be available when the user is building the PAML, the dose and frequency fields are not mandatory. In addition, since some patients may only be able to describe the medication by color, shape, or indication, we allow users to specify the name of the medication in free-text and update the PAML later when the medication is fully identified. The time when the patient last took the medication can also be optionally recorded.
To facilitate interdisciplinary communication among physicians, nurses and pharmacists, the intent of the admitting physician to continue or discontinue a medication upon admission can be easily recorded on the PAML. Any entry on the PAML can be marked as i) ‘continue at pre-admission dose and frequency’; ii) continue at different dose and frequency’; iii) ‘discontinue’; iv) ‘substitute with different medication’. In addition, if the admitting clinician suspects patient non-adherence before admission for a particular medication or if the medication has been temporarily held before admission, a notation can be made under the ‘medication details’ column. If the admitting clinician is unsure about the accuracy of a particular entry on the PAML (e.g., if the patient can only identify a pill by color or is unsure of its dose), the entry can be marked as ‘need to clarify.’
Information for each entry on the PAML can be changed or deleted by any clinician with access to the application (with an audit trail of all changes permanently stored in the PAML repository). For example, if new information about a patient’s outpatient regimen emerges after the initial attempt at building the PAML, the responsible clinician can update the information in the PAML. Once changes to the PAML are saved, the information becomes available to other clinicians who need that information for the medication reconciliation process. The application also allows the user to save a PAML as ‘in progress’ until she or he decides it is ready for review by other clinical disciplines, at which point the clinician will save the PAML as ‘ready for review.’
Using the PAML during Patient Admission
After completing the PAML, the admitting clinician uses the information to construct the admission medication orders using the local CPOE system. Depending on the design of the order-entry screens, the CPOE application displays the PAML as a static list to facilitate decision making (). The PAML Builder application can be summoned on demand if information on the PAML needs to be modified.
Viewing the PAML as inpatient orders are written.
We heard early during the requirement gathering process that clinicians wanted to turn entries in the PAML into admission orders ‘with a click.’ We held off supporting this feature during the first phase of the project for several reasons. First, colleagues around the country who had allowed physicians to turn entries on the paper-based PAMLs into inpatient orders uncovered several issues with this potentially time-saving strategy. For example, they found that physicians would make direct annotations to the paper-based PAML after the initial set of orders were processed, leading to ambiguity as to the actual active orders. We therefore decided that it would be important to use the pilot process to increase understanding of the timing and frequency of changes being made to the electronic PAML before we used the PAML to create inpatient medication orders. Second, recent literature on the unintended consequences of information technology 20,21
suggests that workflow automation may introduce opportunities for new errors if the technology makes it easy for its users to bypass the necessary safety checks. Therefore, our clinical leaders did not want to over-automate the process of medication ordering using the PAML without first understanding how users would use the PAML Builder
application. Third, turning outpatient medication entries encoded with different medication terminologies and non-interoperable information models (for orders and prescriptions in terms of dose, strength, frequency, and instructions) into inpatient orders would require a robust normalization and mapping approach. At the time of this project, the infrastructure to support this normalization and mapping was only in its infancy. Given these issues, the project team deferred the on-demand automatic transformation of outpatient medication entries into full-fledged inpatient medication orders to a later project phase.
Using the Pre-Admission Medication List (PAML) at Patient Discharge
At the time of patient discharge, both CPOE systems at the two academic medical centers support a discharge module that allows users to create the discharge medication orders using the active inpatient medication list. With the use of the PAML Builder application, the PAML can be juxtaposed with the active inpatient medication list at the time of patient discharge so that both lists can be considered in the writing of discharge orders ().
Figure 5 Generating the discharge medication list. To help the provider generate the discharge medication list, the CPOE system at this institution lists all the active inpatient medication lists under the ‘discharge medications’ column. To turn (more ...)
PAML Builder Use across Different Clinical Disciplines
Robust medication reconciliation processes at admission and discharge require collaboration across different clinical disciplines. , , and are cross-functional flowcharts (‘swim lane diagrams’) that depict how our solution set can be used by physicians, nurses and pharmacists to achieve that goal.
Cross-functional flowchart: typical PAML Builder use for medical patient.
Cross-functional flowchart: typical PAML Builder use for elective surgical admission.
Cross-functional flowchart: typical PAML Builder use at patient discharge.
depicts how clinicians use these tools during the admission process for patients admitted through the emergency room to the inpatient medical services. illustrates how clinicians may use the PAML Builder application to handle elective surgical patients who are evaluated days to weeks before the admission and are then admitted formally by the surgical housestaff after the surgery has been completed. describes how the discharging physician and nurse use the information collected through the PAML Builder to ensure that the patient is discharged on the appropriate medication regimen. All 3 figures illustrate how the various clinical disciplines contribute to the process of medication reconciliation and how the PAML Builder application facilitates communication and information sharing across clinical disciplines.