Keep an Eye on Medications

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 - William F. Bria, MD
William F. Bria, MD

Medication formulary management has always been a challenge.  The advent of heath IT should be of great assistance, but without proper integration of medication reconciliation and HIT, there can be unfortunate consequences.

Each healthcare provider has his or her own formulary of desired and recommended medications. Sometimes it is  based on hard medical science or best-of-breed practice, but oftentimes, it’s not.  For example, a pharmaceutical company may make a deal with a healthcare delivery organization to provide the lowest price for antibiotics. A provider  may think she’s  prescribing her patient a certain drug or a comparable equivalent. However, that is not always the case.

Medication reconciliation is much more subtle than just generics and lowest price. The worst case scenario involves a patient who is already on a similar medication under the care of another provider. We’re all familiar with the first-time patient encounter scenario with he or she bringing in their bag of pill bottles. You order them a new set of medications but the patient doesn’t know that one of the new drugs is similar but has a different name. The other doctor told the patient to always take the original medication for high blood pressure. If that patient combines the new antihypertensive medication with the old one, he or she could cause his or her blood pressure to go too low, and experience potentially dangerous sequelae.

This should never happen. Take a step back. Remember what we’re doing to American healthcare right now. We’re producing a process change the likes of which haven’t occurred in day-to-day practice in a generation, thanks to the use of IT. While there are many providers that are doing just fine and have established impressively streamlined workflows, others are confused, stressed and dealing with a disturbance in workflow that is causing them to be very concerned about their efficiency.

There is no question that the adoption of health IT is a distraction. But we believe it’s a necessary and important one to go through. However, this problem of pharmaceutical reconciliation is not trivial. Aside from the bag of meds the patient brings to a first visit, there’s a more subtle form of corruption. The insurance plan has a lot to say about what happens with what is ordered. Sometimes, pharmaceutical substitution happens without the ordering physician even knowing it. It might be told to someone but not necessarily the clinician that was there at the time of the initial order for a drug.

The bottom line is the complexity of information integration. We’re all pretty much aware of the idea of medication reconciliation across location, organization and time. Americans are seeking their care in many different venues, not just in a primary care provider’s office. That care may take place in a local Walgreens with a nurse practitioner, etc.  The idea of the convergence of the adoption of IT combined with the very heterogeneous way that healthcare and medications, in particular, are paid for, delivered and communicated about in our society right now can cause unintended consequences.  We need to be hyper-vigilant. When medication reconciliation is added to the distraction of health IT adoption, there can be conflict.