Penetration of the Medication Reconciliation Educational Program to Clinic Sites
A total of 37/46 (80%) primary care sites implemented the pharmacist delivered medication reconciliation education from April to June 2021 with equal representation from each of Geisinger’s regions during the study observations period. Of the 684 clinical personnel that were eligible for the education, 59% completed the entire education over the 4 weeks (or a modified version) and 81% completed a portion of the education. Eight sites achieved 100% attendance of clinical personnel. Site-level demographics and education delivery information is available in Table 3.
Table 3
Site Demographics and Participation in Medication Reconciliation Educational Program
Site | Region | Practice type | Delivery of education | Number of weeks of education | Adaptations made to timing format of the education | Number of clinical personnel identified as eligible for training | Number of clinical personnel present for the entire training | Percentage of clinical staff that completed entire training | Number of clinical personnel present for at least one training | Percentage of clinical staff that completed partial training (at least one session) |
1 | Central | Primary | Virtual | 3 | Y | 23 | 7 | 7/23 (30.4%) | 15 | 15/23 (65.2%) |
9 | Central | Primary | In-Person | 3 | Y | 5 | 2 | 2/5 (40.0%) | 5 | 100% |
13 | Central | Primary | Virtual | 2 | Y | 6 | 4 | 4/6 (66.7%) | 5 | 5/6 (83.3%) |
15 | Central | Primary | Virtual | 4 | Y | 5 | 5 | 100% | 5 | 100% |
16 | Central | Primary | In-Person | 4 | N | 4 | 4 | 100% | 4 | 100% |
18 | Central | Primary | In-Person | 3 | Y | 20 | 12 | 12/20 (60.0%) | 19 | 19/20 (95.0%) |
19 | Central | Primary | In-Person | 2 | Y | 13 | 6 | 6/13 (46.2%) | 11 | 11/13 (84.6%) |
22 | Central | Primary | In-Person | 1 | Y | 8 | 8 | 100% | 8 | 100% |
24 | Central | Primary | In-Person | 2 | Y | 9 | 8 | 8/9 (88.9%) | 8 | 8/9 (88.9%) |
27 | Central | Primary | Virtual | 2 | Y | 6 | 4 | 4/6 (66.7%) | 6 | 100% |
29 | Central | Primary | Virtual | 1 | Y | 12 | 9 | 9/12 (75.0%) | 9 | 9/12 (75.0%) |
35 | Central | Primary | In-Person | 1 | Y | 7 | 4 | 4/7 (57.1%) | 4 | 4/7 (57.1%) |
36 | Central | Primary | In-Person | 1 | Y | 25 | 10 | 10/25 (40.0%) | 10 | 10/25 (40.0%) |
37 | Central | Primary | In-Person | 1 | Y | 10 | 9 | 9/10 (90.0%) | 9 | 9/10 (90.0%) |
4 | Northeast | Primary | Mix | 4 | Y | 28 | 4 | 4/28 (14.3%) | 19 | 19/28 (67.9%) |
6 | Northeast | Primary | Mix | 3 | Y | 62 | 5 | 5/62 (8.1%) | 20 | 20/62 (32.3%) |
7 | Northeast | Primary | In-Person | 4 | N | 8 | 7 | 7/8 (87.5%) | 8 | 100% |
8 | Northeast | Primary | In-Person | 4 | N | 32 | 2 | 2/32 (6.3%) | 20 | 20/32 (62.5%) |
12 | Northeast | Primary | In-Person | 4 | N | 3 | 3 | 100% | 3 | 100% |
17 | Northeast | Primary | In-Person | 4 | N | 22 | 1 | 1/22 (4.5%) | 12 | 12/22 (54.5%) |
20 | Northeast | Primary | In-Person | 4 | N | 5 | 4 | 4/5 (80.0%) | 4 | 4/5 (80.0%) |
21 | Northeast | Primary | Virtual | 2 | Y | 10 | 10 | 100% | 10 | 100% |
1 | 8 | 8 | 100% | 8 | 100% |
23 | Northeast | Primary | In-Person | 4 | N | 7 | - | - | - | - |
25 | Northeast | Primary | In-Person | 4 | N | 11 | 2 | 2/11 (18.2%) | 10 | 10/11 (90.9%) |
26 | Northeast | Primary | In-Person | 1 | Y | 22 | 8 | 8/22 (36.4%) | 8 | 8/22 (36.4%) |
38 | Northeast | Primary | Virtual | 1 | Y | 15 | 12 | 12/15 (80.0%) | 12 | 12/15 (80.0%) |
3 | West | Primary | In-Person | 3 | Y | 27 | 8 | 8/27 (29.6%) | 22 | 22/27 (81.5%) |
5 | West | Primary | In-Person | 4 | N | 6 | 1 | 1/6 (16.7%) | 6 | 100% |
10 | West | Primary | In-Person | 4 | N | 16 | - | - | - | - |
14 | West | Primary | Virtual | 4 | Y | 10 | 1 | 1/10 (10.0%) | 10 | 100% |
30 | West | Primary | Virtual | 1 | Y | 37 | 22 | 22/37 (59.5%) | 22 | 22/37 (59.5%) |
31 | West | Primary | Virtual | 1 | Y | 6 | 6 | 100% | 6 | 100% |
32 | West | Primary | Virtual | 1 | Y | 19 | 13 | 13/19 (68.4%) | 13 | 13/19 (68.4%) |
33 | West | Primary | Virtual | 1 | Y | 6 | 6 | 100% | 6 | 100% |
34 | West | Primary | Virtual | 4 | Y | 22 | 3 | 3/22 (13.6%) | 15 | 15/22 (68.2%) |
39 | West | Primary | Virtual | 3 | Y | 29 | 10 | 10/29 (34.5%) | 19 | 19/29 (65.5%) |
28 | All | Primary | Virtual | 1 | Y | 100 | 70 | 70/100 (70.0%) | 70 | 70/100 (70.0%) |
11 | Central | Specialty | In-Person | 1 | Y | 6 | 5 | 5/6 (83.3%) | 5 | 5/6 (83.3%) |
2 | West | Specialty | In-Person | 3 | Y | 7 | 5 | 5/7 (71.4%) | 6 | 6/7 (85.7%) |
Fidelity of the Pharmacist to Deliver the Medication Reconciliation Educational Program as Designed
The initial implementation of the educational program targeted primary care clinics; however, 2 specialty clinics also implemented the program. Of the 37 primary care clinics, 10 (27%) completed the medication reconciliation educational program as originally designed and 27 (73%) made some adaptation to the delivery of the program. Adaptations were minor and consisted of consolidation of the educational program into fewer sessions, more frequent sessions to complete the training sooner (e.g.,1 day or 2–3 week programs), or splitting the educational program to target one type of medical personnel at a time (for example, prescribers at one meeting and nurses and medical assistants at another). Other adaptations included hosting the program virtually. A majority (20/37, 54%) of the sites hosted the education in-person while 41% (15/37) held virtual education sessions and 5% (2/37) had a mix of both. These adaptations were made to meet the needs of their individual clinics and clinic personnel.
Interviews were completed with 11 clinic personnel who attended the educational program and 4 pharmacists that delivered the educational program. Detailed demographics for the interviews are available in Table 4.
Table 4
Demographics of survey and semi-structured interview participants
| Pre-survey (n = 296) | Post-survey (n = 178) | P-value | Interview (n = 15) |
Male, N (%) | 41 (14%) | 23 (13%) | 0.83 | 1 (7%) |
Age, N (%) | | | 0.85 | |
18–40 | 129 (44%) | 73 (41%) | | 9 (60%) |
40–60 | 130 (44%) | 81 (46%) | | 3 (20%) |
60 and older | 37 (13%) | 24 (13%) | | 3 (20%) |
Practice area, N (%) | | | 0.37 | |
Primary Care | 276 (93%) | 162 (91%) | | 14 (93%) |
Specialty Care | 20 (7%) | 16 (9%) | | 1 (7%) |
Position type, N (%) | | | 0.29 | |
Physician, PA, CRNP | 90 (30%) | 44 (25%) | | 3 (20%) |
Nurse (RN/LPN) | 131 (44%) | 79 (44%) | | 6 (40%) |
Pharmacist | - | - | | 4 (27%) |
Medical assistants | 34 (11%) | 29 (16%) | | 2 (13%) |
Case manager | 26 (9%) | 21 (12%) | | - |
Community health assistants | 2 (1%) | 0 (0%) | | - |
Other | 13 (4%) | 5 (3%) | | - |
Average number of years in practice Mean (SD) Median (IQR) | 9.3 (10.5) 5 (2, 14) | 8.5 (9.3) 4 (2, 14) | 0.35 | - |
Number of clinics participating | 39 | 36 | - | 12 |
Completed training, N (%) All sessions Some, but not all sessions | - | 123 (69%) 35 (31%) | - | - |
Pharmacists felt the educational program was generally well-received and stimulated good discussion at the clinic sites. Discussion was noted to be more difficult at the clinics which held their training virtually. In addition, the pharmacists were not always able to reach the target group of clinic personnel due to busy schedules, prior engagements, or trainings held over the lunch hour. Pharmacists emphasized how the educational program needs to be ongoing to ensure that everyone is keeping up with new technologies and changes in the electronic health record that affect the medication reconciliation process. Exemplar quotations from pharmacists related to fidelity to the educational program are listed below.
“I guess maybe timewise, just the clinic being too big, not enough time to hit all of the people that you need to. I know with some of the huddles you don't always have every person there, they come and go. There are some people that just never attended a huddle and that was just in the bigger clinics, so you'd miss some. So, just having the time to actually do it.” (106 Pharmacist)
“We have all different sorts of specialties here. So, instead of doing it in the weekly increments, just because there are so many providers that are here and they're all here different days, different hours, I presented it to all the nursing staff early morning on a Thursday. All the nursing staff that deals with all the providers collectively. Gave them all separate power points, and we reviewed it together, one by one, and as a whole in one sitting.” (358 Pharmacist)
“From 1:10 to 1:40 is now considered "lunch" for our providers so they don't typically have patients and nursing a lot of times will kind of start to eat lunch around noon, but a lot of them will kind of peace out during that timeframe because of the fact that there are no providers to be rooming for and there is just a little bit more time, so all of nursing wasn't always able to attend.” (696 Pharmacist)
Acceptability of the Medication Reconciliation Educational Program by Clinic Personnel
A total of 296 clinic personnel completed the pre-survey, while 178 completed the post-survey. There were no statistically significant differences in baseline characteristics between clinic personnel that completed the surveys. Detailed demographics for the pre- and post-survey are available in Table 4.
The pre- and post-surveys explored clinic personnel acceptability and knowledge regarding the educational program on medication reconciliation (Table 5). When asked to indicate their agreement with the following statement, “I am confident that I complete medication reconciliation correctly most of the time,” the percentage of clinic personnel responding "strongly disagree" increased by 5% (2% vs. 7%, p = 0.01) and the percentage responding "strongly agree" increased by 11% (33% vs. 44%, p = 0.02) from the pre- to the post-survey. Thus, the educational program 'polarized' people and made them either more or less confident, with fewer people in the middle. For every category of product (except prescription medications, creams/ointments, eye drops, and "none"), there were statistically significant increases in the percentages of clinic personnel saying those products were important to include in medication reconciliation. There was also a statistically significant increase in clinic personnel correctly selecting the most appropriate behavior consistent with a medication reconciliation, which changed from 78% pre-survey to 91% post-survey (p = 0.0003). While post-survey respondents were also more likely than pre-survey respondents to state that improper medication reconciliation can result in admissions or readmissions (96% vs. 90%, p = 0.02), a correct answer, they were also more likely to state that an improper medication reconciliation may lead to loss of insurance coverage, an incorrect answer (42% vs. 28%, p = 0.002). Clinic personnel felt they learned something from the educational program that would apply to their work (86% said agree or strongly agree), and were likely to recommend the program to a friend (on the Net Promoter Scale of 0–10, mean response was 8.2).
Table 5
Clinic personnel pre- and post-survey responses
Questions | Responses | Pre-survey results (n = 296) | Post-survey results (n = 178) | P-value |
Please indicate your agreement or disagreement with the following statement: I am confident that I complete medication reconciliation correctly almost all the time. | Strongly disagree | 6 (2%) | 12 (7%) | 0.002 |
Disagree | 10 (3%) | 2 (1%) |
Neither agree nor disagree | 32 (11%) | 10 (6%) |
Agree | 151 (51%) | 76 (43%) |
Strongly agree | 97 (33%) | 78 (44%) |
Medication reconciliation is the process of ensuring that a patient’s medication list is complete and accurate. This process includes… (correct answer in bold) | Collecting information from the patient and other sources | 0 (0%) | 0 (0%) | 0.45 |
Comparing that information to information held by the health system (typically in the electronic health record) | 2 (< 1%) | 1 (< 1%) |
Reconciling any differences in medication list | 1 (< 1%) | 0 (0%) |
A and C | 2 (< 1%) | 0 (0%) |
A and B | 3 (< 1%) | 0 (0%) |
All of the above | 288 (97%) | 177 (99%) |
What products are important to include when you perform a medication reconciliation? (correct answers in bold) | Prescription medications | 293 (99%) | 177 (99%) | 0.99 |
Over-the-counter medications | 284 (96%) | 177 (99%) | 0.04 |
Herbal or dietary supplements | 280 (95%) | 176 (99%) | 0.02 |
Creams/ointments | 283 (96%) | 176 (99%) | 0.05 |
Eye drops | 286 (97%) | 177 (99%) | 0.06 |
Lancets | 248 (84%) | 169 (95%) | 0.0003 |
Glucose strips | 255 (86%) | 170 (96%) | 0.001 |
Oxygen | 265 (90%) | 173 (97%) | 0.002 |
None of the above | 14 (5%) | 12 (7%) | 0.35 |
Select the most appropriate behavior consistent with a medication reconciliation. (correct answer in bold) | Ask them closed ended questions about their medication use | 14 (5%) | 9 (5%) | 0.0001 |
Read the medications on their electronic health record to the patient | 51 (17%) | 7 (4%) |
Ask them to tell you the name, dose, strength, and how often they take their medications and confirm with their health record | 231 (78%) | 162 (91%) |
Improper medication reconciliation can result in… (correct answers in bold) | Adverse events | 288 (97%) | 176 (99%) | 0.25 |
Loss of insurance coverage | 83 (28%) | 74 (42%) | 0.002 |
Admissions and/or re-admissions | 265 (90%) | 170 (96%) | 0.02 |
Medication interactions | 286 (97%) | 176 (99%) | 0.23 |
Please indicate your agreement or disagreement with the following statement: I learned something from the training that I will apply to my work | Strongly disagree | | 13 (7%) | |
Disagree | | 4 (2%) | |
Neither agree nor disagree | | 9 (5%) | |
Agree | | 92 (52%) | |
Strongly agree | | 60 (34%) | |
On a scale of 0–10, how likely are you to recommend the medication reconciliation training to a friend? | Mean (SD) | | 8.2 (2.5) | |
Individual scores, N (%) | | Individual scores, N (%) | |
0 | | 8 (4%) | |
1 | | 0 (0%) | |
2 | | 1 (< 1%) | |
3 | | 0 (0%) | |
4 | | 3 (2%) | |
5 | | 16 (9%) | |
6 | | 2 (1%) | |
7 | | 17 (10%) | |
8 | | 31 (17%) | |
9 | | 9 (12%) | |
10 | | 78 (44%) | |
All clinic personnel interviewed felt satisfied with the educational program. Also, all described the program as informative and liked that it provided examples on how to complete the medication reconciliation within the electronic health record. About a third, mostly providers, felt there was no new information that they learned from the education but felt it was a good refresher on the topic of medication reconciliation. Other clinic personnel discussed new learnings from the education including: how to place in a note to the doctor about the medication reconciliation they conducted; making sure dose, frequency, time of day is recorded for each medication the patient is taking; adding reasons for when a medication has been discontinued; and learning how to add natural supplements to the medication list. Exemplar quotes about acceptability of the medication reconciliation educational program by clinic personnel are listed below.
“It was very informative because there were lots of things, I didn't know myself when I was doing med rec because usually, I would just flag them to be taken off instead of taking them off myself, that I could do that. I didn't know I had to put a reason every time I took one off.” (538 Nurse)
“I'm doing it constantly now as far as cleaning up the med rec. I mean we always did make Med reconciliation but now we're actually cleaning up the med rec. We're going in, we're discontinuing the meds, we could use med list cleanup, there's those different dropdown options and such, so yes.” (102 Nurse)
Appropriateness of the Medication Reconciliation Educational Program by Clinic Personnel
All clinic personnel felt the educational program was appropriate because it directly impacted their job. Clinical personnel identified obtaining an accurate medication reconciliation as a very important part of their job. Many nurses discussed how taking a good medication reconciliation helps the prescriber understand what the patient is taking and helps make important decisions about care. Prescribers felt medication reconciliation was important to caring for their patients. Many felt it was appropriate to have refresher education on the medication reconciliation process at some determined point in time or as updates are made to the electronic health record, and to incorporate this type of education into new employee orientation. Exemplar quotes about appropriateness of the medication reconciliation educational program by clinic personnel are listed below.
“I would hope most staff members already know why, but being able to explain to the patient makes them feel more empowered and they're more open to increasing dialogue.” (552 Medical assistant)
“I think it will be very helpful, especially with new hires, because I think that when you get a new hire, like I will be hiring some new nurses, I will be able to implement this in part of their training for beginners training because I think you need to mold them in the beginning and not do the shortcuts, and I think it will be better. It's just everybody has to stay on the same page.” (274 Nurse)
Feasibility to Implement the Medication Reconciliation Skills from the Educational Program into Practice by the Clinic Personnel
Even though clinic personnel felt the educational program was acceptable and appropriate, two major concerns were discussed: lack of patient knowledge and lack of time. Clinic personnel discussed how many patients do not know the names, dose, frequency, or other important aspects of the medications they are taking. This lack of knowledge from the patient creates barriers to implementing the medication reconciliation process described in the educational program. Some personnel recommended patients bring in their bottles or make a list of their medications when they come to the office, but acknowledged it is difficult to achieve. Most clinic personnel also discussed some aspect of time which would impact them from taking a good and accurate medication reconciliation. Some felt they did not have time to determine what medications the patient was taking before the prescriber needed to see the patient. Exemplar quotes about feasibility of the medication reconciliation educational program by clinic personnel are listed below.
“It's hard to do with some patients because they don't even remember what they're taking, and they don't bring a list in, so it's hard to do some of these. For those I just leave a note for the doctor that I tried to do these, and the patient is not very cooperative with it.” (538 Nurse)
“Yeah, so just having to go through and then, one, I don't see them in person, so I can't really have them bring their pills with them, they kind of tell me my blue pill, so it's a little bit difficult for me to discriminate which ones they're taking, and then just kind of going through, because you can like pull in from like outside sources, like trying to pull that in and stuff like that, so it can be little bit time consuming when I'm doing the telemedicine visits.” (638 Physician)
“I think the patient gets in the way. They don't listen. They say they don't know what they're taking. They're on a pill pack. They don't bring in the pills, they don't bring in the pill pack label you know I think it's more patient related than it is anything else.” (102 Nurse)
Adoption of the Medication Reconciliation Skills from the Educational Program into Practice by the Clinic Personnel
A total of 55 observations of nurses and medical assistants were completed across three of the larger ambulatory clinic sites for their adoption of their learnings from the educational program. We found the adherence rate to the elements of the medication reconciliation which were covered in the education program ranged from 0–95% (Table 6). There was no meaningful difference across the three sites where the observations were conducted.
Table 6
Adherence to elements of the medication reconciliation educational program
Elements of Medication Reconciliation | Total n = 55 |
Verified patient’s identity | 52 (95%) |
Verified allergies | 40 (73%) |
Accessed patient’s medical list | 52 (95%) |
Verified preferred pharmacy | 50 (91%) |
Discussed Mail Order Pharmacy as appropriate | 2/2 (100%) |
Reviewed patient’s medication list with the patient | 52 (95%) |
Used ‘go reconcile’ button | 0 (0%) |
Verify Patient’s current medication | 52 (95%) |
Are you using your medication as prescribed? (Dose, Route, Frequency, etc.) | 37 (67%) |
Asked about new medication | 19 (35%) |
Added new medication | 9/19 (47%) |
Asked about discontinued medications | 28 (51%) |
Removed old medications | 14/28 (50%) |
Asked about held medication | 12 (22%) |
Reason discussed for hold, if applicable | 2/12 (17%) |
Marked as held | 8/12 (67%) |
Deleted duplicates, if applicable | 3 (5.4%) |
Asked about side effects (adverse medication reactions) | 3 (5.4%) |
Documentation of reaction | 3/3 (100%) |
Asked about adherence (forgetfulness, trouble taking, or cost) | 6 (11%) |
Ask about over the counter medications | 20 (36%) |
Asked about “as needed’’ medications | 32 (58%) |
Asked about other concerns/questions | 1 (1.8%) |
Make note to Physician, if applicable | 19 (35%) |
Check mark as review | 50 (91%) |