Automation of the Medication History Process: A Case Report

Abstract

Upon admission, medication history is an integral part of the medication reconciliation process; however, it is difficult to obtain one that is accurate and complete. A patient's reliability as historian, in addition to time constraints often placed upon the health care provider are factors that can reduce the accuracy and completeness of a medication history. A system is described that provides medication reconciliation including medication fill and refill information from third-party payers and pharmacy-benefit managers (PBM). Thomas Hospital in Fairhope, Alabama is the initial site deploying the system. Information about the patient's prescription medications is retrieved upon admission and presented to history takers and prescribers, in electronic and/or paper format, as admission orders are being written. Data retrieval and presentation are automatic, and the information is seamlessly integrated into the entire medication reconciliation progression, from admission, through patient transfers, and the discharge process.

Analyzing and amending hospital systems and procedures is a complex and time consuming process. However, when patient care and safety can be significantly and directly impacted, it becomes apparent that the institution must allocate personnel and resources to foster the initiative. Thomas Hospital, a 150 bed acute care facility, in Fairhope, Alabama reviewed its admission, transfer, and discharge procedures with a focus on improving the medication reconciliation process. This commitment resulted in a redesign of the system that included automated retrieval of the patient's medication history.