At Trillium Health Centre the pharmacy department is responsible to ensure that for 90% of the patients admitted to the hospital a BPMH would be achieved. In some cases nurses are responsible, in some cases pharmacists are responsible, etc.
The problem is that people think MedsCheck is the same as MedRec, which in fact is not true. MedsCheck is just a kind of the first stage of the history, but MedRec is not a slur against
MedsCheck. MedRec is a process built in for hospital admission facilities. Changes might be made to the medication regimen of a patient due to many different reasons, e.g. something new is
discovered about the patient, there should be a change to a dose of a medication, and etc. Of notice that all the changes in the hospital are not necessarily communicated to the community and it is essential that the reasons for those changes being articulated accurately why those adjustments are made. MedRec is all about this issue, and is not limited to admission; it should be run for transfers and for discharges as well. MedRec at discharge is that we get the information from community in the admission and we give it back to the community in the discharge. So, it is supposed to be a continuous loop of information circulation. The biggest problem is when a patient is admitted at 3:00 a.m. when most of the pharmacies are closed at that time,15 and if they are open, how fast and
efficiently they can find the information regarding the patient to be admitted, and how quickly this information will be faxed to the hospital, and how quickly the fax is received.16 As it can be seen, it
will take quite some time for a pharmacist at a hospital to wait for the information about the
patient’s medication regimen, and this is why they usually tend to obtain the BPMH themselves and not to wait for MedsCheck from community pharmacies and so on.17
Another issue is that there are not so many patients that have their MedsCheck reviews with them at the time of admission.18 At Trillium Health Centre if a patient would have a MedsCheck list with
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him, they would consider the list as a starting point, but what is certain is that they won’t trust it 100%, and they try to get the information from as many resources as they can.19
Trillium Health Centre has reviewed medications for 6,000 patients, but not anymore, due to the fact that the ministry will not pay them for the MedsCheck service that they are providing. In fact it is believed that the MedsCheck review that was conducted by the Centre had a certain level of trust and that it could be used to reduce the workload at the admission, and was accepted as a base for a treatment of the patient. But from the time that the payment was stopped by the government, it was not financially feasible for the hospital to continue reviewing the patients’ medication regimens. There are two different approaches by the community pharmacists and the hospital pharmacists. Community pharmacies do not have the kind of databases that hospital pharmacies have. They don’t have the information about the patient that the hospital pharmacies have. So, we know everything about a patient who is in the hospital. Pharmacists at the hospitals have collaborations with nurses and physicians which enable them to know exactly what is going on with the patient. They exactly know the reason for certain types of medications ordered for the patients. They understand what is happening in the physicians head when they are prescribing something.20 But
this is not the case with the community pharmacies. When a prescription goes to them, they can only guess that this med is usually prescribed for this type of illness. The community pharmacists do not have such information about the patient unless they establish a strong relationship with the patient, having an ongoing dialogue with the patient and starting putting goals for those patient follow-ups.21 When this happens that community pharmacist has an active player role in decision
making about what kind of therapy. Our aim is to involve our pharmacists in decision making process for the therapy for the patients, but the problem is that we don’t have enough pharmacists to engage them with the treatment of every patient. And it is known that whenever a pharmacist is involved in the treatment process, the mortality rate is decreased. Another difference in the
approach of is that hospital pharmacies are not a business. They are not looking for making profit at all.
The problem for the Trillium Health Centre was that the ministry stated that “you are already getting global funding, why are you billing us for such a service too? Why are you allowed to double dip”? But the fact was that we didn’t want to double dip, we were providing MedsCheck for the patients and the pharmacist should be compensated for the service being offered. Actually, the intention was to achieve a seamless care process, and in that case greater portion of the patients admitted to the hospital would have the pharmacists’ review of their medication regimens. Right now, there is not sufficient number of pharmacists available in the hospital to intervene in the treatment of every single patient.
What can be seen here as the most prominent obstacle is the miscommunication between facilities and institutions. Regarding the lack of an integrated and unified electronic health record system in Ontario,22 it seems to be a big mystery. While British Columbia is using this type of unified system
from late 1990s, why shouldn’t Ontario have such a system yet? Is duplicating such a system an impossible thing? There should be some reasons for not having and not planning to have such a unified and integrated system in Ontario. It is believed with the existence of such HL7 standard making such a database should be a pretty straight forward task.SF3 And then tell everyone that they
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have to use this language for their systems,S2 and it will be done. Therefore, a political will has to be
there to force companies to say what we are doing right now is not the best for the safety of the patients versus the best for their businesses.23
Currently, what we have done is to break down the whole task into technical task and clinical task. Technical task is about gathering information and confirming the information, versus clinical task of assessing and deciding whether this is the optimum and appropriate therapy. Technical task can be done by a technician. Clinical task is to be done by the pharmacist.SF4
There is another problem with today’s electronic systems, as they are not standardized and each setting has its own system and platform,24 when a physician moves from one institute to another
one, he/she has to be trained again to be able to work because there is something completely different there.25
Let’s get them all talk to each other. Let’s share the information. Some systems don’t like sharing of the information. For some bizarre reasons pharmacy systems are the most complex of all. The pharmacy information systems are probably the most complex.26
Another issue about the MedsCheck in the community pharmacies is that from the financial point of view for the business and the industry of the pharmacies, MedsCheck is not proven to be a sufficient profit making task for the pharmacies. Each MedsCheck review may take half an hour, within which time pharmacists can fill ten prescriptions and earn much more than that of the MedsCheck. So, MedsCheck is not financially justifiable for a community pharmacy.13
The connection between the community pharmacy and a hospital pharmacy is not acceptable right now, and this is due to the lack of information transfer between them. Neither community
pharmacist, nor hospital pharmacist tends to give information to the other partner.26 BPMDP is one
solution for that lack of communication and information sharing from the hospital pharmacy to the community pharmacy, in which it is identified the meds to be continued and to be stopped and the reasons for them. It seems to be quite interesting for the community pharmacies, but again there is a problem of standardization. Each healthcare setting has its own forms and community
pharmacies won’t receive a standardized form with certain components in it.27
One of the big debates in hospital pharmacy is the whole idea of discharge counseling. Being logical it’s easy to realize the issue here. 28 First of all there are not enough pharmacists available to
counsel patients about their discharge plan. Secondly the patient is going to fill the prescription at the community pharmacy, and it is an obligation for the pharmacists to counsel patients for the meds being dispensed at their pharmacies. So there will be duplication of work. Thirdly, the low level of confidence in the whole system requires such a task to be done by the hospital
pharmacists,29 when there won’t be any prescriptions being filled. Right now, I don’t have any
pharmacists to do things which will evidently decrease mortality, how can I allocate my resources for a task for which there is no evidence in literature that discharge counseling will decrease the mortality.
The problem regarding the flow of information between facilities is not a new issue, and there have been examples of that before, such a dialogue between the specialists and the general physicians
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(GP), where a specialist has to fill in a kind of a discharge form for the GP, and that it is done on paper and it is time consuming.
Regarding the MedsCheck program, once it was carried out at the Trillium Health Centre, patients welcomed it very openly and they really liked the program, in the way that it became somehow another issue for the center, when patients come back and asked for more reviews (more than once a year), and again lack of resources didn’t allow the center to help them. But what can be said is that patients were quite satisfied with the service.30 And from his point of view this type of
communication between a patient and a pharmacist is the one that should really exist. Because we all know that medications are the cause for all the harms and at the same time cause for all the wellness. It is known that 10% of the patients are re-admitted to hospitals due to medical reasons and medical mistakes. So, involving pharmacists in such services can definitely reduce the harms and prevent such mistakes to damage patient’s health.
For the future plans of the center, he believes that investments in CPOE and these types of systems will not help a lot,S3 and instead establishing a type of the barcoding system for the pills and
patients is much more beneficial. He believes by using these systems they will help staff to do the right thing correctly, and they will decrease the large amount of mistakes occurring at the bedside, where the actual pill administering and Meds taking is happening. He states that Kaizen methods are not effective in such huge and complex systems, rather the incremental continuous
improvements are more advantageous.S4 One example of deploying such quality improvement tools
was the use of Six Sigma for preventing the messy meds concept in different wards of the hospital, and the project was successful.
He declares that if the community pharmacists knew that the hospital pharmacists and clinicians base their treatment on that MedsCheck done by them, they would do it more carefully and the outcome would be much more trustable. But currently the pharmacies believe that the MedsCheck is a local phenomenon, and it is basically for education of that particular patient, and as far as this is their understanding the interface between community pharmacies and the hospital pharmacies will not develop as it should be.31 Also, the same problem arises from the hospitalists side when using
that MedsCheck is not yet their priority and focusing more on their own systems inside the hospital in order to make them as efficient as possible distract them from improving that kind of dialogue between the hospitalists and community pharmacists. Another issue is the frequency of the patients who has the MedsCheck reviews done before. If every single patient that comes in the hospital has done the MedsCheck review before, then it is more accountable for the hospital pharmacies to consider that and use that the way it is designed for.18
The problem with the case why MedRec is not performed for 100% of the patients originates from the lack of resources and not the system of the hospital.8 This is what you can figure out from
talking with all the hospitals and it should be taken into account by the ministry.
Computer system force behavior is an essential element to improve the electronic flow of information, and free up some working hours of the staff, which enables them to cover more numbers of patients in MedRec.33 But the funding to start such systems is not approved yet. These
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whole process, and this is the place where change management strategies become essential, and this is one of the toughest tasks to do. To change the way things are done, to change the culture, to change the behavior of the physicians, and then monitoring the adherence to these systems.32