IntroductionComprehensive Medication Management (CMM) is a collaborative patient‐centered approach to medication optimization. We recently implemented telephonic CMM as part of a multidisciplinary team within a team‐based at‐home care program. The objective of this study was to describe the type and frequency of medication therapy problems (MTPs) identified by pharmacists delivering CMM as part of this program, as well as the acceptance rates of the recommendations made to rectify them.MethodsWe conducted a retrospective chart review of all patients receiving CMM within the program between December 12, 2018 and December 31, 2019. We identified and classified MTPs based on the framework developed by the Pharmacy Quality Alliance. Descriptive statistics were used to determine the quantity of MTPs, as well as the acceptance rates of the recommendations.ResultsWe identified 307 patients who received CMM. Of these patients, 58% were female (178/307) and 96% identified as White (296/307). Average age was 72 years old (SD 13). On average, pharmacists identified 4 MTPs/patient with a 35% acceptance rate (431/1228) for their recommendations. Of those accepted, pharmacists were able to resolve 185 (43%) of these MTPs on their own while providers resolved the remaining 246 (57%) MTPs. Acceptance of MTPs was more likely if patients were spoken to (38.4% vs 29.5%, relative risk [RR] = 1.30, 95% CI 1.10‐1.54, P = .002).ConclusionsPharmacists were able to identify several MTPs when conducting telephonic CMM within a team‐based at‐home care program. These MTPs and their associated recommendations however, often failed to be resolved. Recommendations were more likely to be resolved if patients were spoken to, highlighting the importance of engaging the patient as part of CMM. Future studies should examine ways to improve intervention acceptance as well as the clinical and economic impact of changes made as a result of telephonic CMM and MTP identification.

Objectives To understand the extent to which behaviors consistent with high quality medication reconciliation occurred in primary care settings and explore barriers to high quality medication reconciliation. Design Fully mixed sequential equal status design including ethnographic observations, semi-structured interviews, and surveys. Setting Primary care practices within an integrated healthcare delivery system in the United States. Participants We conducted 170 observations of patient encounters across 15 primary care clinics, 48 semi-structured interviews with staff, and 10 semi-structured interviews with patients. We also sent out surveys to 2,541 eligible staff with 616 responses (24% response rate) and to 5,132 eligible patients with 577 responses (11% response rate). Results Inconsistency emerged as a major barrier to effective medication reconciliation. This inconsistency was present across a variety of factors such as the lack of standardized workflows for conducting medication reconciliation, a lack of knowledge about medication and the process of medication reconciliation, varying levels of importance ascribed to medication reconciliation, and inadequate integration of medication reconciliation into clinical workflows. Findings were generally consistent across all data collection methods. Conclusion We have identified several barriers which impact the process of medication reconciliation in primary care settings. Our key finding is that the process of medication reconciliation is plagued by inconsistencies which contribute to inaccurate medication lists. These inconsistencies can be broken down into several categories (standardization, knowledge, importance, and inadequate integration) which can be targets for future studies and interventions.

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Background Despite routine review of medication lists during patient encounters, patients’ medication lists are often incomplete and not reflective of actual medication use. Contributing to this situation is the challenge of reconciling medication information from existing health records, along with external locations (eg, pharmacies, other provider/hospital records, and care facilities) and patient-reported use. Advances in the interoperability and digital collection of information provides a foundation for integration of these once disparate information sources. Objective We aim to evaluate the effectiveness of and satisfaction with an electronic health record (EHR)-integrated web-based medication reconciliation application, MedTrue (MT). Methods We conducted a cluster-randomized controlled trial of MT in 6 primary care clinics within an integrated health care delivery system. Our primary outcome was medication list accuracy, as determined by a pharmacist-collected best-possible medication history (BPMH). Patient and staff perspectives were evaluated through surveys and semistructured interviews. Results Overall, 224 patients were recruited and underwent a BPMH with the pharmacist (n=118 [52.7%] usual care [UC], n=106 [47.3%] MT). For our primary outcome of medication list accuracy, 8 (7.5%) patients in the MT arm and 9 (7.6%) in the UC arm had 0 discrepancies (odds ratio=1.01, 95% CI 0.38-2.72, P=.98). The most common discrepancy identified was patients reporting no longer taking a medication (UC mean 2.48 vs MT mean 2.58, P=.21). Patients found MT easy to use and on average would highly recommend MT (average net promoter score=8/10). Staff found MT beneficial but difficult to implement. Conclusions The use of a web-based application integrated into the EHR which combines EHR, patient-reported data, and pharmacy-dispensed data did not improve medication list accuracy among a population of primary care patients compared to UC but was well received by patients. Future studies should address the limitations of the current application and assess whether improved implementation strategies would impact the effectiveness of the application.

Introduction. Improper medication reconciliation can result in inaccurate medication lists which can lead to adverse events including hospitalizations. Interventions targeting medication reconciliation have had varying levels of success. To improve medication reconciliation practices in our ambulatory care clinics, we developed an educational program for clinic personnel. The objective of this study is to describe the educational program, its implementation in a healthcare system, pharmacist and clinic personnel perception of the program, and its impact on clinic personnel knowledge and practice. Methods. Guided by the Conceptual Model of Implementation Research, we conducted an evaluation of a pharmacist-led educational program on evidence-based practices for medication reconciliation by examining implementation outcomes. The implementation outcomes measured include penetration, fidelity, acceptability, appropriateness, feasibility, and adoption. Data was collected through direct observations, administrative data, pre- and post-surveys, and semi-structured interviews. Results. A total of 37/46 (80%) primary care sites implemented the pharmacist delivered medication reconciliation education from April to June 2021 with representation from each of Geisinger’s regions. Ten (27%) clinic sites completed the medication reconciliation educational program as originally designed, with the remainder adapting the program. 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 who completed the pre- vs. post-survey. Interviews were completed with 11 clinic personnel who attended the educational program and 4 pharmacists who delivered the educational program. All clinic personnel interviewed felt satisfied with the educational program and felt it was appropriate since it directly impacted their job. While clinic personnel felt the educational program was acceptable and appropriate, two major concerns were discussed: lack of patient knowledge about their medications and lack of time to complete the medication reconciliation. We found the adherence rate to the elements of the medication reconciliation which were covered in the education program ranged from 0% to 95% in the 55 observations conducted.Conclusion. An educational program for medication reconciliation was found to be acceptable and appropriate but was often adapted to fit site specific needs. Additional barriers affected adoption of best practices and should be addressed in future studies. Trial registration. N/A