Original Research

Medication List Discrepancies and Therapeutic Duplications Among Dual Use Veterans

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References

Interview Summaries

Veterans and medication. Multiple non-VA providers said that the primary reason veteran patients were going to a VA provider was to obtain discounted medications. The use of the VA for medications also was a way for the non-VA provider to discover that the patient was a veteran. One non-VA provider was particularly concerned about the impact of new or different medications from VA prescribers on efforts to stabilize the patient’s chronic condition.

Several non-VA providers reported that veterans often brought a medication list to the appointment, and several providers recommended the practice to their patients. Non-VA providers preferred to have patients transfer information from VA, sometimes requesting that veterans bring in their records from recent appointments rather than the non-VA provider obtain the information directly from the VA.

Information sharing. Non-VA providers generally preferred hard copies of medication lists and other documents rather than scans because they were more likely to be included in decision making if the documents were presented during the visit. Also, document scans may be buried in the electronic medical record. Some providers mentioned their interest in electronic transfer of medical information like medication lists if the technology were more developed and better integrated.

“I think the long-term vision would be that it should be electronic… it wouldn’t necessarily be feasible at this time. Our system scans paper documents in to an e-version. … but when the patient comes to their encounter 10 days later, you don’t realize the stuff’s there… Having the patient bring them in is probably a more certain way to make sure that it’s actually included in your decision making as a provider.”

Most non-VA providers welcomed more information such as imaging studies because they reported rarely receiving this information from the VA system. Two mentioned the potential for too much information and wanted concise reports should the flow of information increase. Providers had little interest in logging in to a patient’s online health record portal as a delegate for reasons related to complexity, time, privacy, and lack of mechanism to document the information accessed.

Medication reconciliation. Non-VA providers generally reported that patients bringing their own or an outside medication list would prompt a process of medication reconciliation. The providers were interested in making changes to their records based on other lists, but outside data were verified against a patient self-report of actual use before adopting changes.

“I print out my med list of what I have in the computer and then I just check off my list against their list. And then whatever’s remaining, we talk about what the differences are, when they were changed, what they were changed for, if they were taken off of something, and if I don’t agree, then I’ll tell the patient, ‘look, there’s a disagreement here, they’ve told you not to be on this. I want you on this.”

Should a discrepancy arise, non-VA providers generally had a negative view of attempting to contact VA providers. Other mechanisms such as calling a local pharmacy would be done first.

Discussion

This study provided initial evidence that medication list discrepancies exist for dual use veterans. Other studies of medication list discrepancies have linked such inconsistencies to medication-related problems and negative outcomes for patients.27 Although efforts to increase access to care for veterans have advantages related to expediency, consequences to fragmenting care exist. More robust mechanisms for establishing and maintaining medication list consistency are needed, especially given the lack of a universally accepted medical record format or repository. A multifaceted approach, including patient engagement, seems necessary.

This study also showed that discrepancies of high-risk medications are common for veteran participants, placing them at risk for medication-related problems and harm. These risks included dose and frequency discrepancies that could result in over- or underdosing of medications and in medication omissions, which could cause duplicative therapies and unnecessary risks. For example, aspirin frequently was listed on non-VA lists but was omitted from VA medication lists. This could be problematic for patients who present to the VA for a procedure in which no information about aspirin could jeopardize their safety. Insulin doses also were commonly discrepant, which could impact glycemic control.

Many providers also had incomplete prescribing information for opiates. Those prescriptions are particularly relevant given the link between veterans, posttraumatic stress disorder, depression, and substance abuse.28-30 However, it was beyond the scope of this pilot study to link these discrepancies to ADRs, such as emergency department visits or hospital admissions. Other studies have demonstrated that discrepancies at hospital discharge can result in these types of negative outcomes.27,31 Subsequent research should determine the clinical significance of discrepancies that occur when veterans are dual users.

The qualitative interviews provided some initial context on prescriber perspectives about the role of veterans participating in the medication list sharing process and personal health records. It seemed that for the portion of patients who brought a list to their non-VA provider appointment, the information was welcomed but fell outside the usual visit workflow. Many provider visits are dominated by current patient symptoms, and issues of reconciling medications may be a lower priority.32 Also, some providers may delegate medication reconciliation functions to a nurse or other support staff. One physician offered that he delegated logging in to a patient’s online medication information to a health coach on staff. These findings were consistent with perspectives shared by non-VA family practice physicians about personal health records.33

The most common way to integrate outside medication lists into the non-VA provider’s medical record seemed to be scanning the document. Scanning had its limitations because the provider might be unaware of the scanned document, and there were no mechanisms to import medication names and doses. However, the process may improve only the non-VA providers’ records, as they reported that they had no easy or consistent way to transmit medication changes to notes to the VA.

In general, communicating with VA providers was seen as not feasible and not worth their time or effort. It may be beneficial to address this non-VA provider concern because it seems to inhibit the transfer of important health information and the maintenance of a concordant medication record. Information transfer is particularly relevant for veterans who are primarily cared for by non-VA providers and use the VA only to get prescription medications.

In the current approach, non-VA providers have no simple, direct way to update the VA medication list. Transmitting updates carries the risk of inappropriate changes and is concerning if neither or both prescribers consider themselves to be responsible for the patient’s medications. Also, the potential exists for all medication lists to be inaccurate if the lists do not reflect the medications patients take when left on their own. Patient nonadherence rates can exceed 50%, depending on the medication.34,35 Several interviewed non-VA physicians stressed the importance of asking patients to list the medications they were using during the medication reconciliation process.

This study offers several areas for additional inquiry, including understanding how providers make sense of medication lists from other sources and what technologies can be applied to increase list consistency without increasing the burden on providers.

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