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The importance of medicine reconciliation
Another of the new elements of a comprehensive eye examination is the medicine reconciliation. Although most of us have collected some kind of information about our patient’s medicine list, we often were just listening for a medicine that might affect the eyes or vision. We perked up when he heard, “prednisone” or “Plaquenil” (hydroxychloroquine, Sanofi-Aventis) but, other than that, we just made a general list and moved on.
As a member of the primary health care team, we now must collect specific information on each medicine that our patient consumes and reconcile this with the patient’s medical conditions from our review of systems. We then must provide this information back to the patient and develop a way to transmit this information back to the primary care physician and the other members of the team.
This is a tall order and one that we have needed to phase into our busy practice. In our first month with our electronic health record (EHR), the medicine reconciliation consumed the entire time slot for the examination. We have learned that the listing of the medicines can be a task of our technical staff, but the reconciliation of the list to the review of systems is part of the direct optometrist-to-patient time. It is stunning to learn how many patients do not know which medicines are used for which medical condition. Also, many patients fail to list common medical problems during the review of systems because they believe that the medicine cured the problem. “I had high blood pressure, but the doctor gave me some pills and now I don’t have it anymore.” This requires me to go back and amend the review of systems and add a cardiovascular problem.
So, why do we, as optometrists have to do this? The answer is in the above paragraph. We have to do this as a member of the primary health care team because the current system is not providing enough information and education to our patients so that they can effectively understand and manage their own health care. The comprehensive eye examination is another opportunity to reinforce the nature of medical problems and the reason for the medicines that are being consumed. This is especially important because we are a nonthreatening, friendly, comfortable source of health education and information. This does not mean that we have to the expert on complex medical treatments and procedures, but rather the basic primary health care problems such as hypertension, diabetes and cholesterol issues.
In addition to reinforcing the primary health treatment plans, we have a key role in the management of some of these problems. When we see a diabetic patient, many people in the health care system think this is just a simple question: “Retinopathy? Yes or no?” If this is all that is needed, the primary care doctor could just take a photo in their office and ship it off to a “fundus reading center” for a quick answer. In fact, many are using this system today.
However, this simple approach is why we are losing the war on chronic health problems like diabetes in America. Health care reform, in the true spirit of the law, was created to improve this situation. The primary health care optometrist, as part of the team, will see a patient who is asymptomatic and believes that they are healthy. In doing the review of systems and medicine reconciliation, the optometrist learns that the patient has an HA1c of 8.1, doesn’t take their metformin consistently because they thought that was for their blood pressure, hasn’t seem their PCP for a while because the wait in the office is too long, is getting their medicine by mail order with automatic renewal and has gained 10 pounds in the last 3 months. Even without retinopathy, this patient is in trouble and needs education, counseling and a prompt referral to the PCP with this information summarized by the primary health care optometrist.
So, medicine reconciliation is a key aspect of the primary health care optometrist’s comprehensive eye examination. We need to learn to do it well and to use the information effectively to take our place as an important member of the primary health care team in health care reform.