Medication reconciliation is the comprehensive evaluation of a patient’s
medication regimen any time there is a change in therapy in an effort to avoid
medication errors such as omissions, duplications, dosing errors, or drug
interactions, as well as to observe compliance and adherence patterns. This process
should include a comparison of the existing and previous medication regimens and
should occur at every transition of care in which new medications are ordered,
existing orders are rewritten or adjusted, or when the patient has added
nonprescription medications to his or her self-care.
9 Although not a new concept to
the profession of pharmacy, there has been heightened awareness and intensified
effort in this area of practice as a result of the Joint Commission. In 2005, the Joint
Commission announced its National Patient Safety Goal (NPSG) 8A and 8B to
accurately and completely reconcile medications across the continuum of care. This
goal requires institutions to develop and test processes for medication reconciliation
in ambulatory and acute care settings.
In 2015, the Joint Commission’s NPSG 3 has
continued its focus on improving the safe use of medications, in particular by
maintaining and communicating accurate patient medical information.
The Centers for Medicare & Medicaid Services (CMS), the largest purchaser of
health insurance in the United States, is directly connecting reimbursement for
Medicare services to patient outcomes. CMS developed star ratings as a means to
move away from the Pay-for-Service Model of healthcare and move toward a new
quality based or Pay-for-Performance Model. CMS annually rates Medicare health
plans on a scale of 1 to 5 stars, with 5 stars representing the highest quality. The
overall scores are based on more than 50 care and service quality measures across
five categories, including staying healthy, managing chronic conditions, member
satisfaction, customer service, and pharmacy services. Specific to pharmacy
services, CMS assesses Medicare prescription drug plans (MA-PD’s or PDPs) using
its rating scale, focusing on five quality measures. Two of those quality measures
assess medication safety, while the other three evaluate adherence. The quality
measures that focus on safety look at decreasing the amount of high-risk medications
(HRMs) in patients 65 and older and whether diabetic patients who also have
hypertension are taking an ACE Inhibitor, Angiotensin Receptor Blocker (ARB), or
Direct Renin Inhibitor. (To view complete list of HRM’s visit website:
measures that focus on evaluating the level of adherence of patients who are on
medications for diabetes, hypertension, or hypercholesterolemia, specifically
In August 2013, CMS released a study demonstrating that in 2010 Medicare
Part D MTM programs improved therapy outcomes, most notably adherence, on
patients who had congestive heart failure (HF), chronic obstructive pulmonary
disease, and diabetes compared to those who did not receive such services.
It is important for pharmacists to realize that MTMS are integral to improving
health outcomes and are continuing to gain acceptance from payers, in both the
private and public sectors. The opportunity for pharmacists to continue to expand
their role, while offering high level care, along with the potential for improvement in
pharmacy compensation is in line with the CMS star ratings.
The general approach to an MTMS patient encounter in various clinical settings
will be discussed in the next sections. Figure 1-1 provides a visual representation of
a systematic process for a comprehensive and effective approach for delivering
SOURCES OF PATIENT INFORMATION
Successful patient assessment and monitoring requires gathering and organizing
3,14 The patient (or family member or representative) is always
the primary source of information. The provider asks the patient a series of questions
to obtain subjective information that is helpful in making a diagnosis or evaluating
ongoing therapy. Likewise, providers without direct access to patient data must also
obtain subjective data or measure objective physical data to guide recommendations
for therapy and to monitor previously prescribed therapy.
Figure 1-1 General approach to an MTMS patient encounter. (Reproduced from the American Pharmacists
Association [APhA], with permission.)
Data-Rich and Data Poor Environments
In a “data-rich environment,” such as a hospital, long-term facility, or outpatient
medical clinic, a wealth of information is available to practitioners from the medical
record, pharmacy profile, and medication administration record (MAR). In these
settings, physicians, nurses, other health care providers, and patients are readily
available. This facilitates timely, effective communication among providers involved
in the drug therapy decision-making process. Objective data (e.g., diagnosis, physical
examination, laboratory and other test results, vital signs, weight, medications,
medication allergies, intravenous flow rates, and fluid balance) are readily
available. The patient record provides information that is needed to identify and
assess medical problems, which is necessary to design patient-specific care plans
and document MTMS. In some settings, patient insurance information is important to
help understand the formulary choices and access to medications.
In a “data-poor environment,” such as a community pharmacy, clinicians are often
required to make assessments with limited information. Although the information may
be limited to (a) the medication profile, (b) patient demographic data, (c) medication
allergy history, and (d) the patient’s insurance coverage, it is still valuable.
The information in Table 1-1 is an illustrative summary of sources of patient
Sources of Patient Information
Data-Rich Environment Data-Poor Environment
Decreasing use across the practice continuum
Not consistent from site to site
Difficult to access, if more than one user
Electronic Health Record (EHR)
Electronic version of a paper chart
Differs across practice settings
One of the most complete sources of reliable
Can interface with other software systems in the
Data shared between systems in real time
Pharmacy Information Systems (PIS)—
Mainly focus on pharmacy billing, inventory
management, production of medication labels
Limited documentation of clinical pharmacy
Pharmacy information systems (PIS) are generally considered data poor. Early PIS
were established for pharmacy billing and inventory management. These initial
systems provided fill lists, generated patient profiles, and produced medication
labels, which were valuable to institutional pharmacies as the profession moved
toward a unit dose medication distribution system. More modern functionalities
allow for some limited documentation of clinical pharmacy activities, but still PIS is
An initiative by the US Department of Health and Human Services, called the EHR
Incentive Program, exemplifies the importance of the integration of PIS with other
15 This initiative, the “Meaningful Use of an EHR,” allows
Medicare and Medicaid to provide incentive payments to providers and hospitals for
the “meaningful use” of certified health information technology products. Eligibility
for these incentive payments involves transitioning PIS to a more data-rich clinical
information system (CIS), which includes direct computerized physician order entry,
clinical decision support, an EHR, an electronic medication administration record
(eMAR), and integration of various information systems, such as pharmacy and
laboratory services. Additional functionality incorporates the use of bar code
technology, which allows the ability to track and promote quality assurance during
the medication administration process. Information generated by the CIS is
electronically transmitted to the pharmacy in real time, eliminating lost, illegible, or
In a data-poor environment, the clinician must be a proactive interviewer and may
become an investigator. The investigative approach is direct and requires strong
problem-solving abilities and active listening skills. Questions should be formulated
to obtain information such as the medication history, actual medication use, patient
perception of care, use of over-the-counter (OTC) and natural or herbal products,
and health beliefs (cultural or otherwise). This approach can help to verify and
ensure the accuracy of other data sources. Clinicians should be mindful that not all
patients are reliable historians, and some are poor sources of information. Even
when the patient is a poor historian, the interview provides critical information (e.g.,
indicator of poor adherence, need for a caregiver or interpreter) that cannot be
EFFECTIVE COMMUNICATION AND THE
The ability to use effective communication principles and history-taking skills is
crucial to a successful patient interaction.
3,14 The importance of interviewing the
patient, how to set the stage for the interview, general interview rules, and the
essential information to be obtained from the interview are outlined in Table 1-2.
Information obtained from the patient is critical for assessment and planning in MTM.
Motivational Interviewing (MI) is another useful method created by Miller and
Rollnick that can be utilized during patient counseling to improve patient adherence
to therapy. It is an empathetic and collaborative style of counseling based on five key
principles: expressing empathy, developing discrepancy, adapting to resistance,
avoiding arguments, and supporting self-efficacy, as seen in Table 1-3. The basis of
MI is aimed to improve a patient’s ambivalence to drug therapy through behavioral
changes. It should be noted that motivational interviewing does not require a long-
standing pharmacist–patient relationship to be effective, because individual sessions
have been shown to be helpful.
Importance of Interviewing the Patient
Establishes professional relationship with the patient to:
Obtain subjective data on medical problems
Obtain patient-specific information on drug efficacy and toxicity
Assess the patient’s knowledge about, attitudes toward, and pattern of medication use
Formulate plans for medication teaching and pharmaceutical care
How to Set the Stage for the Interview
Have the patient complete a written health and medication questionnaire, if available
Make the setting as private as possible
Encourage the patient to be descriptive
Clarify by restatement or patient demonstration (e.g., of a technique)
Read the chart or patient profile first
Ask for the patient’s permission to conduct an interview or make an appointment to do so
Begin with open-ended questions
History of adverse drug reactions
Drugs: dose, route, frequency, and reason for use
Perceived efficacy of each drug
Adherence to prescribed drug regimen
Nonprescription medication use (including complementary and alternative medications)
Possibility of pregnancy in women of childbearing age
Family or other support systems
Source: Teresa O’Sullivan, PharmD, University of Washington
Principles of Motivational Interviewing
Convey to your patient that you understand their condition. This will allow the patient to be more
Point out to the patient that there is a difference between current behavior and being able to reach
Use different approaches to encourage the patient to channel their resistance into positive change.
Do not argue with your patient or force them to view things as you do.
Assist the patient with believing that their own decisions will make a difference to behavioral
change. Instead of telling the patient what to do, empower them to figure out what will be
Style. Available from: http://www.ncbi.nlm.nih.gov/books/NBK64964/
Those who provide MTMS should develop standardized forms to record patient
information obtained from the patient interview. Standardization facilitates quick
retrieval of information, minimizes the inadvertent omission of data, and enhances the
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