Reconciling Medications for Admission

Reconciling medications refers to the process of avoiding inadvertent inconsistencies across transitions in care. It involves reviewing the patient’s complete medication regimen at the time of admission and comparing it with the regimen being considered for the new setting of care. Commure Pro Mobile Medication Reconciliation™ allows physicians to reconcile their patients’ home medications and hospital orders when they are evaluating a course of treatment for admission and discharge. This chapter describes how to reconcile your patients’ home medications when you are evaluating a course of treatment for admission to a hospital. These medications are typically pulled from a third-party system. Once you start the admission medication reconciliation process, you can reconcile your patient’s medications in one of the following ways:

• Reconciling with No Home Medications
• Reconciling with Home Medications
• Reconciling Home Medications after Completing Admission Medication Reconciliation You can also view both previously reconciled and existing hospital medications. See Viewing Existing Orders within Admission Medication Reconciliation

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Starting Mobile Admission Medication Reconciliation

To begin the process of reconciling a patient’s home medications with your plan of care, you need to review the list to ensure its accuracy as follows:

• From the Orders menu
• From the Unreconciled Medications alert

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Reconciling Home Medications from the Orders Menu

1. From the Patient List screen, select a patient.
2. When the View Modules list displays, select Orders. The Orders module displays.
3. Select the Orders drop-down menu at the top of the screen, and then select Admission Med Rec from the list. A list of home medications to reconcile displays along with any expiring orders and existing hospital orders.
4. Review the list of medications under the Home Medications to Reconcile section and choose one of the following actions:
   • If the patient has no home medications, proceed to Reconciling with No Home Medications.
   • If the patient has home medications, proceed to Reconciling with Home Medications.

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Reconciling Home Medications from the Unreconciled Medications Alert

If you have any patients with unreconciled home medications on your patient list, you may see an Unreconciled Medications pop-up alert display within the Orders module for a patient (if this feature is enabled in your user profile). You can enter the Admission Med Rec screen directly from this alert as follows:

1. From the Patient List screen, select a patient.
2. When the View Modules list displays, select Orders. The Orders module display, and then the Unreconciled Medications pop-up alert displays.
3. Select Reconcile to enter the Admission Med Rec screen. A list of home medications to reconcile displays along with any expiring orders and existing hospital orders.
4. Review the list of medications under the Home Medications to Reconcile section and then reconcile each home medication. See Reconciling with Home Medications.

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Reconciling with No Home Medications

If the patient is not taking any home medications, you can reconcile the patient as having no known home medications from the Admissions Med Rec screen as follows:

• Select the radio button if it is not already preselected next to No known home medications, and then select Sign & Submit to complete the reconciliation.

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Reconciling with Home Medications

If your patient is taking medications prior to admission, you must reconcile all these medications before admitting the patient unless your facility allows partial medication reconciliation (check with your administrator). Complete the following procedure to reconcile the medications:

1. Choose a course of action for each home medication (See Choosing a Course of Action for Hospitalization). If you are doing a partial medication reconciliation, only select a course of action for the home medications that you wish to reconcile. While you decide the course of action for each home medication, you can also choose to do the following:
   • (Optional) Make changes to the list of home medications if needed. See Changing the Home Medications List.
   • (Optional) Discontinue an active existing order for a home medication. See Discontinuing an Existing Order.
   • (Optional) Add a new hospital order. See Adding a Hospital Order.
   • (Optional) Delete a new hospital order. See Deleting a New Hospital Order.
   • (Optional) Modify a new or existing hospital order. See Modifying a New Hospital Order.

2. Tap Sign & Submit to reconcile and submit the home medication order(s) and any hospital orders. See Reconciling Home Medications after Completing Admission Medication Reconciliation. If there are no warnings or alerts to resolve, your reconciliation is complete. If there are warning and alerts to resolve, go to the next step.
3. Review and resolve any medication interaction warnings and alerts (see Reviewing Interaction and Duplicate Order Alerts), and then resubmit the orders.

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Choosing a Course of Action for Hospitalization

For each home medication you need to decide to either stop, continue, or change it as a hospital order for admission. You cannot complete the reconciliation process until every home medication has a course of action unless your facility allows you to submit a partial medication reconciliation (check with your administrator). The Home Medications to Reconcile section displays a list of unreconciled home medications with a yellow caution symbol (displayed as a yellow exclamation mark) to indicate an action is required. Any home medication that you choose to continue or change will become a hospital order when you complete the reconciliation. If the home medication has an existing hospital order of the same therapeutic class, you will see different actions to choose from when you try to continue or change it (see Choosing an Action for a Therapeutic Class Match).

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Stopping a Home Medication for Admission

If you determine that a home medication is no longer required for admission, you can choose to stop it upon admission as follows:

• Tap Stop located next to the home medication.

The Stop icon turns red . If you stopped a home medication in error, you can undo the Stop order action as long as you do so prior to submission for reconciliation. You can undo the Stop order action in one of the following ways:

• Tap the red Stop to return it to the unselected state.
• Use the right-to-left swipe on the home medication row, select More , and then select Reset from the menu options.
• Tap Expand/Collapse located to the far right side of the home medication, tap Undo from the Home Medication screen, and then select Reset from the menu.

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Continuing a Home Medication for Admission

You can continue the home medication as a hospital order if there are no changes required.

1. Tap Continue/Change in the home medication row, and then select Continue.

The Continue/Change icon turns green and the hospital order displays under the home medication with the prefix New: and the New Hospital Order icon . The order is then ready for reconciliation. If either the Order Search window or Order Details window displays, proceed to the next step.

2. If the Order Search screen displays, your order does not have a valid route or a matching order. You must select the correct medication in the search results. If the Order Details screen appears, you have CDS alerts or missing required information. Review any CDS alerts and complete any highlighted required information, and then tap Save.

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Changing a Home Medication for Admission

You can modify the home medication or choose a different medication for inclusion to the list of Hospital Orders upon admission.

1. Tap Continue/Change in the home medication row, and then select Change.

The Order Search window displays any possible matching Formulary (including matching medications in the same therapeutic class) and Non-Formulary (if enabled) medications. You now have the ability to either change to a different medication in the same therapeutic class or modify the existing medication.

2. Select the desired medication, using one of the following ways:
   • To modify one or more of the details of the existing home medication, select the same medication with the desired changes from the list of search results; or
   • To change to a medication in the same therapeutic class, select the desired new medication from the list of medications. If you select a medication that has all the required information completed, the Continue/Change icon turns green**** and the hospital order displays under the home medication with the prefix New: and the New Hospital Order icon displays. The order is then ready for reconciliation. If the Order Details screen displays, proceed to the next step to complete your changes.
3. Review any CDS alerts that are displayed and enter any changed or new information (including required information) into the Order Details window, and then tap Save.

The Continue/Change icon turns green**** and the hospital order displays under the home medication with the prefix New: and the New Hospital Order icon displays. The order is then ready for reconciliation.

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Choosing an Action for a Therapeutic Class Match

If there are no NDC, medication, brand, or generic matches between a home medication and the patient’s existing hospital medications, the system will determine if there are any therapeutic class matches. If a therapeutic class match exists between a home medication and an existing order for the patient, selecting the Continue/Change icon will bring up the Therapeutic Equivalent Medications pop-up. Choose one of the following appropriate actions:

• Choose Substitute w/Existing Medication to continue the medication as the existing order.
• Choose Not Therapeutic Equivalents to unlink the home medication with the matched hospital order. The medications are unlinked and you can now choose to Continue or Change the home medication.

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Changing the Home Medications List

It is important to have an accurate list of home medications for an accurate reconciliation. If you determine that any medication is missing, incorrect, or mistakenly added, you can make changes to the patient’s list of home medications by either adding, correcting, or deleting a home medication.

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Adding a Home Medication

If you determine that the list of home medications is missing a home medication, you can add a new home medication as follows.

1. Tap the Add icon at the upper right corner of the Admission Med Rec screen, and then select Add Home Medications. The Order Search screen displays.
2. Enter the name of the home medication in the search field, and then select the order from the search results. If the Order Details screen displays, review any CDS alerts that are displayed and complete any missing fields, and then tap Save. The selected order has a check next to it. The Review (n) button in the upper right corner increments to display that the order was added and ready for reconciliation.
   You can also select an order from your list of Favorites.
3. Tap Review (n) in the upper right corner of the screen to review the added home medication in the Admission Med Rec screen.

The added home medication displays at the top of the home medications list with the Unreconciled New Home Medication icon and is ready to be reconciled.

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Correcting a Home Medication

If you determine that the home medication information is not correct, you can modify it as follows.

1. Select the home medication under Home Medications To Reconcile. The Order Details screen displays with the current medication information.
   If your order does not have a valid route or a matching order, the Order Search screen displays and you will need to choose an appropriate medication order.
2. Review any CDS alerts and make the desired changes to the Order Details screen, and then tap Save.
   • If you edit a home medication that came from a third-party system, the original home medication gets discontinued, the revised medication is displayed under the original medication order.
   • If you revise a home medication that you added within Commure Pro Medication Reconciliation (but not submitted), the home medication order updates to display any changes.

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Deleting a Home Medication Entered in Error

If you discover that a home medication was incorrectly entered, you can remove it as follows:

• Select the home medication to display the Order Details screen. Tap Trash , and then select Delete, or
• Use the right-to-left swipe on the home medication to select Delete . If the home medication was added in Commure Pro, the medication is removed from the Home Medications to Reconcile list. If the home medication came from a third-party system, the home medication displays with Delete: in the list. You will need to submit the change to get the home medication removed from the list.

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Discontinuing an Existing Order

If your patient’s home medication matches an existing order, you will see the existing order under the home medication with the prefix Existing:. No action is needed unless you wish to discontinue the existing order. You can choose to discontinue that order as follows:

• Select the existing medication order to display the Order Details screen, and then tap DC , or
• Use the right-to-left swipe on the existing medication to select DC.

The existing order displays with the prefix Discontinue: and the Discontinue Medication Order icon . The Stop icon turns red.

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Adding a Hospital Order

You can add more medication orders to your patient’s list of hospital orders. You may also add new non-medication orders or order sets. You can add a new order, repeat an existing order using the Order Again feature, or use a free text order (if enabled) to add an order that isn’t found using the search function.

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Adding a New Order

Add any type of new order to the list of Hospital Orders as follows.

1. Tap the Add icon at the upper right corner of the Admission Med Rec screen, and then select Add Hospital Orders. The Order Search screen displays.
2. Select an order from your list of Favorites or enter the name of the order, and then select the order from the search results. If the Order Details screen displays, review any CDS alerts that are displayed and complete any missing fields.

Tap Save to add the order. The selected order has a check next to it.

3. Tap Review (n) in the upper right corner of the screen to review the added order in the Admission Med Rec screen.

The added hospital order displays in the Hospital Orders section under the Home Medications to Reconcile section with a new order icon specific to the type of order added. The order is ready for reconciliation unless a warning or an alert needs resolution.

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Repeating an Existing Order

You can repeat an existing lab or test from within the Admission Med Rec screen.

1. Scroll down to the Existing Hospital Orders section, and then select the lab or test result. The Order Detail screen displays.
2. Select Order Again

• If there are no CDS alerts, and the order doesn’t require additional information, you are returned to the Admission Med Rec screen, and the new order is added to the Hospital Orders section with the either the Lab Result or the Test Result icon that displays a green Order Again icon.

• Review any CDS alerts that are displayed, complete any required information, and then tap Save. You are returned to the Admission Med Rec screen, and the new order is added to the Hospital Orders section with the either the Lab Result or the Test Result icon that displays a green Order Again icon.

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Using Free Text to Add an Order

If you do not find any matches for your order using the Search function, you can choose to add it as a free text order if your system is enabled with this capability as follows:

1. From the Search screen, the name of the entered order with the description Free Text or Free Text Medication (if you entered a medication order) displays. Select this order. If the order is a generic Free Text order, choose the order type. The following happens:
   • If you added a Free Text order, it is added to the Hospital Orders section. You will need to select the order to display the Order Details to make any changes.
   • If you added a Free Text Medication order, the Order Details screen displays.
2. Enter the desired information into the available fields including any required fields, and then select Save. The new order is added to a either the Home Medications to Reconcile section or the Hospital Orders, depending on whether you chose to create a free text medication order from a home medication or as an added hospital order.

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Deleting a New Hospital Order

If you decide you no longer need a new hospital order (prior to submitting it), you can delete the new order as follows:

• Select the home medication to display the Order Details screen. Tap Trash , and then select Delete, or
• Use the right-to-left swipe on the hospital order to select Delete . The hospital order is removed from the Hospital Orders section.

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Modifying a New Hospital Order

If you need to change any of the unsubmitted new hospital orders, you can modify the order as follows.

1. Select the order listed under the Hospital Orders section. The Order Details screen displays.
2. Review any CDS alerts and make any desired changes, and then tap Save. The modified order displays under the Hospital Orders section with the modified information. The order is ready for reconciliation.

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Reconciling New Hospital Orders

After you have decided upon an action for home medications, and added any new hospital orders, you are ready to complete the reconciliation process. Once you tap Sign & Submit , all of the patient’s new orders are submitted at once. After you select the Sign & Submit button, you may be required to enter your Commure Pro password or a numeric PIN (Personal Identification Number). Or, if Apple’s Touch ID® or Face ID® feature has been set up on your device (see Establishing a Touch ID or Face ID for Logging In or Signing Orders), and has also been enabled by your administrator, you can use your fingerprint to sign your orders instead of a manually entering a password or PIN. Depending on how your administrator has configured the system, any one of the following scenarios may apply:

• You are never required to enter a password or PIN (or to use Touch ID or Face ID) after you select the Sign & Submit button.
• You are required to enter a password or PIN the first and every time that you select the Sign & Submit button. If Apple’s Touch ID or Face ID feature is enabled on your device, after you enter your password or PIN the first time, you are then prompted to use the Touch ID or Face ID feature (instead of password or PIN) each time you select the Sign & Submit button.
• You are required to enter a password or PIN the first time you select the Sign & Submit button, and then the application “remembers” your this information for subsequent submissions in the same session. You are not required to enter it again unless you have a period of inactivity (no new order submissions) that is longer than a specific period of time defined by your administrator. Again, if Apple’s Touch ID for Face ID feature is enabled on your device, after you enter your password or PIN the first time, you are then prompted to use the Touch ID/Face ID feature (instead of password or PIN) whenever you have a period of inactivity that is longer than the defined time.

• In addition, your administrator may require you to enter the name of a provider who can co-sign the orders for you. This feature can be enabled for all orders, or just certain types. To sign and submit all your new orders for a given patient, follow the steps below.

1. On the Admission Med Rec screen, tap Sign & Submit .
2. If not all the home or hospital medications have an action, a pop-up displays asking if you want to stop the remaining medications or if you want to submit a partial reconciliation (must have partial reconciliation enabled at your facility). Select Stop Remaining Meds or Submit Anyway (partial reconciliation).
3. If an additional password, PIN, or co-signing provider are required, the Signature screen is displayed, containing one or more of the dialogs below is displayed. Complete each screen as follows, depending on what it requires:
   • Manual Entry of Password or PIN: Manually enter your password or PIN, and then tap Done.
   • Manual Entry of Password or PIN, plus Co-Signing Provider: Manually enter your password or PIN, and then enter the name of the co-signing provider (using the Search field or the Recently Selected list), and then tap Done. If only one provider can co-sign for you, that name is defaulted into the field for you.
   • Touch ID or Face ID in place of Password or PIN: If Touch ID or Face ID is enabled (and your Touch ID/Face ID has been established via Establishing a Touch ID or Face ID for Logging In or Signing Orders), then immediately after you tap Sign & Submit one of the following dialogs is displayed:
   • For Touch ID: “Touch ID for Commure Pro. Sign using your fingerprint.” Press your finger lightly on the Home button to register your fingerprint and immediately sign your orders. If your fingerprint is not accepted for any reason, a Sign using pin/password option is automatically displayed. If you select this option, the Password or PIN field is shown. Enter your password or PIN and then tap Done. - For Face ID: The Face ID logo is shown. Show your face to the front camera to register your identity and immediately submit your orders. If your facial image is not accepted for any reason, a Try Face ID Again option is automatically displayed. Select the option and try again. Or tap Cancel, tap into the Password or PIN field, enter your password or PIN, and then tap Done.

• Co-Signing Provider: If a password or PIN are not required, or if you used Touch ID/Face ID in place of manually entering the password or PIN, you may next see a dialog asking for the name of the co-signing provider. Enter their name using the Search field or the Recently Selected list, and then select Done. If only one provider can co-sign for you, that name is defaulted into the field for you. Each of the patient’s new orders are now checked for interactions or duplicates.
• If none are found, the order is submitted to the server and moves to the Existing Orders section. If you were required to enter a co-signing provider, the orders are then routed to the co-signing provider for signature, and they are also added to the patient’s Existing Orders list.

• If the order has errors, an alert or warning describing the error is displayed. You can correct the issue and submit again, or you can discard the order. See Reviewing Interaction and Duplicate Order Alerts.

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Understanding Unsubmitted Orders

A patient’s new orders accumulate either in the Home Medications to Reconcile or Hospital Orders section until you sign and submit them. If your device is not connected to the server at the time that you select the Sign & Submit button, or if you exit the Admission Med Rec section of the Orders module without selecting the Sign & Submit button, the new orders are not submitted. The orders remain on your device as long as you do not discard them. There are multiple safeguards in place to ensure that you do not forget to submit these orders. Please note that in all cases below, the application notifies you about only those new unsubmitted orders that you created on this mobile device. Unsubmitted orders that you created on a different mobile device or on the desktop Medication Reconciliation application are not included.

• Yellow Caution Symbol: For each patient that has new unsubmitted orders, an exclamation mark highlighted in yellow is displayed next to the patient’s name on the Patient List, to highlight that fact. You can submit the orders when you are ready, by going to the Admission Med Rec section of the Orders module for that patient and tapping the Sign & Submit button. Or, if you decide you do not want to submit the orders after all, you can tap the Discard All button to discard all the new unsubmitted orders.
• Numeric Red Badge on the Pending Button: If you have one or more unsubmitted orders for any of your patients, the Pending button (located in the bottom tool bar of the application) will have a red badge with a number:. This number indicates the total number of your unsubmitted orders, draft notes, and unsigned documents. Tap the Pending button to view the Notifications screen. If the Unfinished Orders item has a number after it, such as Unfinished Orders 3, this indicates the number of unfinished orders. Select the Unfinished Orders option to view the Unfinished Orders screen, which displays a list of all your unsubmitted orders, sorted by patient. Under each patient’s group of orders, there are two options:

• : Tap Go to Orders to go to the Admission Med Rec section of the CPOE Orders module for this particular patient, where you will see the unsubmitted orders listed in the Home Medications to Reconcile section and any unsubmitted orders in the Hospital Orders section. You can then modify, sign and submit, or discard the orders.
• : Tap Discard All to discard all of the unsubmitted orders for this patient.
• Text Alert when Logging Out: If you log out of Commure Pro while you still have unsubmitted orders, the following warning message is displayed: “You have [n] unsubmitted orders. Are you sure you want to log out?” You are then presented with options to keep the orders and log out, discard the orders and log out, or cancel logging out. If you keep the orders and log out, you will not receive any text notifications about them. However, the unsubmitted orders will remain on the device (flagged with the yellow icon until you log back in again and either submit or discard them.
• Text Alert when the Device Times Out: If the Commure Pro application times out while you have unsubmitted orders, a single text notification is displayed after five minutes to remind you that you have unsubmitted orders. Launch the Commure Pro application, and as described above, the patients with unsubmitted orders will be flagged with the yellow icon so that you can quickly identify them and address their orders. Or you can ignore the message; the unsubmitted orders will remain on the device (flagged with the yellow icon until you log back in again and either submit or discard them.

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Reconciling Home Medications after Completing Admission Medication Reconciliation

If your patient should have home medications added after you submitted and reconciled them for admission or only a partial medication reconciliation was completed, you can return to the Admission Medication Reconciliation window and reconcile these home medications as follows:

1. Start the Admission Medication Reconciliation process as described in Starting Mobile Admission Medication Reconciliation.
2. Reconcile any new or existing home medication as described in Reconciling with Home Medications.

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Viewing Existing Orders within Admission Medication Reconciliation

You can review any existing hospital medication orders, expiring orders, or previously reconciled medication orders within the Admission Med Rec screen by scrolling down the screen. All orders functionality for existing orders is available within the Admission Med Rec screen. See Managing New and Existing Orders for more information.