Comparison of Information Available in the Medication Profile of an Electronic Health Record and the Inpatient Best Possible Medication History in a Mother and Child Teaching Hospital Center.

BackgroundMedication reconciliation (MedRec) can improve patient safety. In Canada, most provinces are implementing electronic health records (EHR). The Quebec Health Record (QHR) can theoretically be used for medication reconciliation. However, the quantity and the quality of information available in this EHR have not been studied. ObjectivesThe main objective was to compare the quantity and quality of the information collected between the inpatient best possible medication history (BPMH) and the QHR.   MethodsThis is a descriptive prospective study conducted at CHU Sainte-Justine, a 500-bed tertiary mother-and-child university hospital center. All inpatients from May 19-26, 2015 were considered for inclusion. Every prescription line in the BPMH and QHR were compared. ResultsThe study included 344 patients and 1,039 prescription lines were analyzed. The medications' name and dosing were more often available in the QHR (95%) than in the BPMH (61%). Concordance between the medication names between QHR and BPMH was found in 48% of the prescription lines; this rate fell to 29% when also factoring daily dosage.  ConclusionsThis study suggests that the QHR can provide high-quality information to support the MedRec hospital process. However, it should be used as a second source to optimize the BPMH obtained from a thorough interview with the patient and/or his or her family. More studies are required to confirm the most optimal way to integrate the QHR to the MedRec process in hospitals.