Documentation of Current Medications in the Medical Record
Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications' name, dosage, frequency and route of administration.
Quality Insights of Pennsylvania
Centers for Medicare & Medicaid Services
National Quality Forum
Finalized Date/Time
Limited proprietary coding is contained in the measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. Quality Insights of Pennsylvania disclaims all liability for use or accuracy of any Current Procedural Terminology (CPT [R]) or other coding contained in the specifications.
CPT (R) contained in the Measure specifications is copyright 2007-2014 American Medical Association.
LOINC (R) copyright 2004-2014 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms (R) (SNOMED CT [R]) copyright 2004-2013 [2013-09] International Health Terminology Standards Development Organization. All Rights Reserved.
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In the American Medical Association’s (AMA) Physician’s Role in Medication Reconciliation (2007), critical patient information, including medical and medication histories, current medications the patient is receiving and taking, and sources of medications, is essential to the delivery of safe medical care. However, interruptions in the continuity of care and information gaps in patient health records are common and significantly affect patient outcomes. Consequently, clinical judgments may be based on incomplete, inaccurate, poorly documented or unavailable information about the patient and his or her medication.
Medication safety efforts have primarily focused on hospitals; however, the majority of health care services are provided in the outpatient setting where two-thirds of physician visits result in writing at least one prescription (Stock et al., 2009). Chronically ill patients are increasingly being treated as outpatients, many of whom take multiple medications requiring close monitoring (Nassaralla et al., 2007).
Adverse drug events (ADE) prove to be more fatal in outpatient settings (1 of 131 outpatient deaths) than in hospitals (1 of 854 inpatient deaths) (Nassaralla et al., 2007). According to The Commonwealth Fund report (2010), about 11 to 15 of every 1,000 Americans visit a health care provider because of ADE in a given year, representing about three to four of every 1,000 patient visits during 1995 to 2001. The total number of visits to treat ADEs (VADEs) increased from 2.9 million in 1995 to 4.3 million visits in 2001.
ADE in the ambulatory setting substantially increased the healthcare costs of elderly persons and estimated costs were $1,983 per case. Further findings of The Commonwealth Fund studies additionally identified 11% to 28% of the 4.3 million visit related ADEs (VADE) in 2001 might have been prevented with improved systems of care and better patient education, yielding an estimate of 473,000 to 1.2 million potentially preventable VADEs annually and potential cost-savings of $946 million to $2.4 billion.
In the Institute for Safe Medication Practices, The White Paper on Medication Safety in the U.S. and the Roles of Community Pharmacists (2007), the American Pharmaceutical Association identified that Americans spend more than $75 billion per year on prescription and nonprescription drugs. Unnecessary costs include: improper use of prescription medicines due to lack of knowledge costs the economy an estimated $20-100 billion per year; American businesses lose an estimated 20 million workdays per year due to incorrect use of medicines prescribed for heart and circulatory diseases alone; failure to have prescriptions dispensed and/or renewed has resulted in an estimated cost of $8.5 billion for increased hospital admissions and physician visits, nearly one percent of the country's total health care expenditures.
In 2005, the rate of medication errors during hospitalization was estimated to be 52 per 100 admissions, or 70 per 1,000 patient days. Emerging research suggests the scope of medication-related errors in ambulatory settings is as extensive as or more extensive than during hospitalization. Ambulatory visits result in a prescription for medication 50 to 70% of the time. One study estimated the rate of ADEs in the ambulatory setting to be 27 per 100 patients. It is estimated that between 2004 and 2005, in the United States 701,547 patients were treated for ADEs in emergency departments and 117,318 patients were hospitalized for injuries caused by an ADE. Individuals aged 65 years and older are more likely than any other population group to require treatment in the emergency department for ADEs. (AMA, 2007).
A Systematic Review on “Prevalence of Adverse Drug Events in Ambulatory Care” finds that “The median ADE prevalence rate for retrospective studies was 3.3% (interquartile range [IQR] 2.3–7.1%) vs 9.65% (IQR 3.3–17.35%) for prospective studies. Median preventable ADE rates in ambulatory care-based studies were 16.5%, and 52.9% for hospital-based studies. Median prevalence rates by age group ranged from 2.45% for children to 5.27% for adults, 16.1% for elderly patients, and 3.45% for studies including all ages (Tache et al., 2011).”
The Agency for Healthcare Research and Quality’s (AHRQ) National’s Healthcare Disparities Report (2011) identified the rate of adverse drug events (ADE) among Medicare beneficiaries in ambulatory settings 50 per 1,000 person-years. In 2005, AHRQ reported data on adults age 65 and over who received potentially inappropriate prescription medicines in the calendar year, by race, ethnicity, income, education, insurance status, and gender. The disparities were identified as follows: older Asians were more likely than older Whites to have inappropriate drug use (20.3% compared with 17.3%); Older Hispanics were less likely than older non-Hispanic Whites to have inappropriate drug use (13.5% compared with 17.6%); Older women were more likely than older men to have inappropriate drug use (20.2% compared with 14.3%); there were no statistically significant differences by income or education.
Weeks et al. (2010) noted fragmented medication records across the health care continuum, inaccurate reporting of medication regimens by patients, and provider failure to acquire all of the necessary elements of medication information from the patient or record, present significant obstacles to obtaining an accurate medication list in the ambulatory care setting. Because these obstacles require solutions demonstrating improvements in access to information and communication, the Institute of Medicine and others have encouraged the incorporation of IT solutions in the medication reconciliation process. In a survey administered to office-based physicians with high rates of EMR use, Weeks et al. found there is an opportunity for universal medication lists utilizing health IT.
The Joint Commission’s 2014 Ambulatory Care National Patient Safety Goals guide providers to maintain and communicate accurate patient medication information. Specifically, the section “Use Medicines Safely NPSG.03.06.01” includes the following: “Record and pass along correct information about a patient’s medicines. Find out what medicines the patient is taking. Compare those medicines to new medicines given to the patient. Make sure the patient knows which medicines to take when they are at home. Tell the patient it is important to bring their up-to-date list of medicines every time they visit a doctor” (Joint Commission, 2014, retrieved at: http://www.jointcommission.org/assets/1/6/2014_AHC_NPSG_E.pdf).
The National Quality Forum’s 2010 update of the Safe Practices for Better Healthcare, states healthcare organizations must develop, reconcile, and communicate an accurate patient medication list throughout the continuum of care. Improving the safety of healthcare delivery saves lives, helps avoid unnecessary complications, and increases the confidence that receiving medical care actually makes patients better, not worse. Every healthcare stakeholder group should insist that provider organizations demonstrate their commitment to reducing healthcare error and improving safety by putting into place evidence-based safe practices.
The AMA’s published report, The Physician’s Role in Medication Reconciliation, identified the best practice medication reconciliation team as one that is multidisciplinary and--in all settings of care--will include physicians, pharmacists, nurses, ancillary health care professionals and clerical staff. The team’s variable requisite knowledge, skills, experiences, and perspectives are needed to make medication reconciliation work as safely and smoothly as possible. Team members may have access to vital information or data needed to optimize medication safety. Because physicians are ultimately responsible for the medication reconciliation process and subsequently accountable for medication management, physician leadership and involvement in all phases of developing and initiating a medication reconciliation process or model is important to its success.
Higher score indicates better quality.
NQF ID Number
Disclaimer
These performance measures are not clinical guidelines and do not establish a standard of medical care, and have not been tested for all potential applications.
THE MEASURES AND SPECIFICATIONS ARE PROVIDED “AS IS” WITHOUT WARRANTY OF ANY KIND.
eMeasure Identifier
68
measureStartDate
measureEndDate
American Medical Association (2007). The physician’s role in medication reconciliation: Issues, strategies and safety principles. Retrieved from http://www.ama-assn.org/resources/doc/cqi/med-rec-monograph.pdf
Stock, R., Scott, J., & Gurtel, S. (2009). Using an Electronic Prescribing System to Ensure Accurate Medication Lists in a Large Multidisciplinary Medical Group. The Joint Commission Journal on Quality and Patient Safety; 35(5), 271-277.
Nassaralla, C.L., Naessens, J.M., Chaudhry, R., et al. (2007). Implementation of a medication reconciliation process in an ambulatory internal medicine clinic. Quality and Safety in Health Care 2007; (16), 90-94.
The Commonwealth Fund (2010). Adverse Drug Events: Ambulatory Care Visits for Treatment. Retrieved from http://www.commonwealthfund.org/Performance-Snapshots/Medication-Mistakes-and-Adverse-Drug-Events/Adverse-Drug-Events--Ambulatory-Care-Visits-for-Treatment.aspx
Institute for Safe Medication Practices (2007). A White Paper on Medication Safety in the U.S. and the Roles of Community Pharmacists. Retrieved from http://www.ismp.org/pressroom/viewpoints/CommunityPharmacy.pdf
Agency for Healthcare Research and Quality (2011). National Healthcare Disparities Report 2011. Retrieved from http://www.ahrq.gov/research/findings/nhqrdr/nhqr11/chap3.html
Weeks, D.L., Corbette, C.F., Stream, G. (2010). Beliefs of Ambulatory Care Physicians about Accuracy of Patient Medication Records and Technology-Enhanced Solutions to Improve Accuracy. Journal for Healthcare Quality; 32(5), 12-21.
The Joint Commission (2014). Ambulatory Care National Patient Safety Goals. Retrieved from http://www.jointcommission.org/assets/1/6/2014_AHC_NPSG_E.pdf
National Quality Forum (2010). Safe Practices for Better Healthcare– 2010 Update. Retrieved from http://www.qualityforum.org/Projects/Safe_Practices_2010.aspx
Tache, S.V., Sonnichsen, A., & Ashcroft, D.M. (2011). Prevalence of Adverse Drug Events in Ambulatory Care: A Systematic Review. The Annals of Pharmacotherapy, 45(7-8), 977-989. doi: 10.1345/aph.1P627.
Current Medications:
Medications the patient is presently taking including all prescriptions, over-the-counters, herbals and vitamin/mineral/dietary (nutritional) supplements with each medication’s name, dosage, frequency and administered route.
Route:
Documentation of the way the medication enters the body (some examples include but are not limited to: oral, sublingual, subcutaneous injections, and/or topical)
This measure is to be reported for every encounter during the measurement period.
Eligible professionals reporting this measure may document medication information received from the patient, authorized representative(s), caregiver(s) or other available healthcare resources.
This list must include all prescriptions, over-the-counter (OTC) products, herbals, vitamins, minerals, dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration.
This measure should also be reported if the eligible professional documented the patient is not currently taking any medications.
By reporting the action described in this measure, the provider attests to having documented a list of current medications utilizing all immediate resources available at the time of the encounter.
Transmission Format
TBD
Initial Patient Population
All visits occurring during the 12 month reporting period for patients aged 18 years and older before the start of the measurement period
Denominator
Equals Initial Patient Populations
Denominator Exclusions
None
Numerator
Eligible professional attests to documenting, updating or reviewing the patient’s current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosages, frequency and route of administration
Numerator Exclusions
Not Applicable
Denominator Exceptions
Medical Reason:
Patient is in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient’s health status
Measure Population
Not Applicable.
Measure Observations
Not Applicable.
Supplemental Data Elements
For every patient evaluated by this measure also identify payer, race, ethnicity and sex.
CLINICAL QUALITY MEASURE SET
Population criteria
-
Initial Patient Population =
- AND: "Patient Characteristic Birthdate: birth date" >= 18 year(s) starts before start of "Measurement Period"
- AND: "Occurrence A of Encounter, Performed: Medications Encounter Code Set" during "Measurement Period"
-
Denominator =
- AND: "Initial Patient Population"
-
Denominator Exclusions =
- None
-
Numerator =
- AND: "Procedure, Performed: Current Medications Documented SNMD" during "Occurrence A of Encounter, Performed: Medications Encounter Code Set"
-
Denominator Exceptions =
- AND: "Procedure, Performed not done: Medical or Other reason not done" for "Current Medications Documented SNMD " during "Occurrence A of Encounter, Performed: Medications Encounter Code Set"
Patient Characteristic Birthdate: birth date
Measurement Period
Occurrence A of Encounter, Performed: Medications Encounter Code Set
Measurement Period
Initial Patient Population
Denominator
Procedure, Performed not done: Medical or Other reason not done
Occurrence A of Encounter, Performed: Medications Encounter Code Set
Denominator
Procedure, Performed: Current Medications Documented SNMD
Occurrence A of Encounter, Performed: Medications Encounter Code Set
Data criteria (QDM Data Elements)
-
"Encounter, Performed: Medications Encounter Code Set" using "Medications Encounter Code Set Grouping Value Set (2.16.840.1.113883.3.600.1.1834)"
-
"Patient Characteristic Birthdate: birth date" using "birth date LOINC Value Set (2.16.840.1.113883.3.560.100.4)"
-
"Procedure, Performed not done: Medical or Other reason not done" using "Medical or Other reason not done SNOMEDCT Value Set (2.16.840.1.113883.3.600.1.1502)"
-
"Procedure, Performed: Current Medications Documented SNMD" using "Current Medications Documented SNMD SNOMEDCT Value Set (2.16.840.1.113883.3.600.1.462)"
Medications Encounter Code Set
Procedure, Performed: Current Medications Documented SNMD
Procedure, Performed not done: Medical or Other reason not done
Patient Characteristic Birthdate: birth date
Encounter, Performed: Medications Encounter Code Set
Reporting Stratification
- None
Supplemental Data Elements
-
"Patient Characteristic Ethnicity: Ethnicity" using "Ethnicity CDCREC Value Set (2.16.840.1.114222.4.11.837)"
-
"Patient Characteristic Payer: Payer" using "Payer SOP Value Set (2.16.840.1.114222.4.11.3591)"
-
"Patient Characteristic Race: Race" using "Race CDCREC Value Set (2.16.840.1.114222.4.11.836)"
-
"Patient Characteristic Sex: ONC Administrative Sex" using "ONC Administrative Sex AdministrativeSex Value Set (2.16.840.1.113762.1.4.1)"
Patient Characteristic Sex: ONC Administrative Sex
Patient Characteristic Race: Race
Patient Characteristic Ethnicity: Ethnicity
Patient Characteristic Payer: Payer