e Health Initiative: Medication Gaps 1
Assignment 4: eHealth Paper
Medication Gaps at
Hospital Discharge
University of Minnesota
N5115, Spring 2009
Group 2
Jolene Dickerman, Denise Frederick,
Tom Lewison, Chris Pensinger,
Sue Strohschein, Andrea Szkarlat
e Health Initiative: Medication Gaps 2
We have chosen to examine the DHHS/Office of the National Coordinator
for Health Information Technology’s December 2008 Medication Gaps use case.
This assignment specifically addresses medication reconciliation issues at the
point of patient discharge from an inpatient facility to self-care at home.
Description of Clinical Focus and Importance to the eHealth Initiative
The medication education at discharge is vital to a patient’s health. During
discharge there are many steps and people involved in the medication
reconciliation process. In our example, the hospital uses a computer system to
form a list of medications, but upon discharge the patient is given a paper form
with an updated list of their medications. According to the Joint Commission of
Accreditation, patients have an increased risk of medication errors at discharge.
Most frequently the error is omission of a medication that the patient was
receiving prior to admission (2006). Because medication errors can be very
serious, it is both important and relevant to address this issue. We need to aid
the patients to become better consumers of their own health. As Weaver et al
(2006) note:
“…the role of citizens as active consumers of health care
information will increase. This consumer behavior in turn will increase the
demand for health care information comprehensible for a lay person and
health personnel with informatics skills to support patients’ use of and
access to information technology to manage their own health. “
The eHealth initiative is vastly expanding and necessary for the move
forward into the world of health care informatics. The electronic health record
(EHR) is quickly becoming the standard and expectation of care in all settings.
e Health Initiative: Medication Gaps 3
By incorporating the medication reconciliation process into the EHR we can
better serve our patients.
The Minnesota eHealth Initiative has set a timeline of 2015 to mandate
that all hospitals and health care providers convert to an interoperable EHR.
Some of the expectations that an EHR will offer for health care employees and
their patients is e-prescribing, synchronization of patient data, lab result
management, and timely clinical decision support. This list is not all inclusive as
there are more improvements to health care that will be possible with a
conversion to an EHR. The overall purpose of this mandate is to improve health
and health care in Minnesota. The vision of the Minnesota e-Health Initiative is
to:
“… Accelerate the adoption and effective use of health information
technology to improve health care quality, increase patient safety, reduce
health care costs and enable individuals and communities to make the
best possible health decisions
According to the e-Health initiative there are many benefits of the
EHR that is specific to our Use Case. A few examples of these are medication
interaction alerts, alerts to contraindications of prescribed medication, and
reduction in errors of prescribed medications by avoiding the use of handwritten
prescriptions.
Is this the part from Question #3?
As stated briefly above, the Use Case we chose is the process of
medication reconciliation at the point of discharge from an inpatient facility to selfcare at home. The current process involves multiple steps and a number of
e Health Initiative: Medication Gaps 4
resources to complete this process. Due to the number of steps and people
involved, the chance of error is greatly increased. This process is quite time
consuming, which can read out to an increased need of resources and cost. The
current system only allows for a paper copy, an electronic version is not
available.
The main objectives we have for our use case are as follows: to promote
accurate medication reconciliation at time of discharge through an EHR; improve
patient safety; increase patient knowledge and understanding of prescribed
medications; create interoperability; maintain focus on the needs of the patient
regarding medication reconciliation.
Discharge Medication Reconciliation: Gap in Care
Question 2: (Sue)
Describe a gap in care that exists related to your proposed use case based on
current functional requirements. Include a high level diagram from previous
assignments to show potential gaps in care and describe these. (5 Pt)
[insert diagram and explanation about here]
Proposed Use Case and Objectives
Question 3 (Denise)
Briefly describe your proposed use case and the objectives you want to achieve.
(10 Pts)
We discovered after looking at this process, that there were so many people
involved in the med rec process at discharge. It is unbelievable how many
people were needed to make a med DC list.
The use case we chose is Medication Reconciliation at the point of discharge
from an inpatient facility to self-care at home.
 Current process involves many steps and people
 Due to number of steps, increased chance of error
 Time consuming, which equals more resources and this means more cost
 Medication list is a paper copy, no electronic version available
 Promote accurate medication reconciliation at time of discharge through
an EHR
e Health Initiative: Medication Gaps 5




Improve patient safety
Increase patient knowledge and understanding of prescribed medications
Create interoperability
Maintain focus on the needs of the patient regarding medication
reconciliation
eHealth Initiative and Use Case
Question 4 (Andrea)
Relate how your proposed use case fits with the overall vision, mission, and
mandate of the eHealth initiative. (10 pts)
The Minnesota e-Health initiative’s vision is “to accelerate the adoption
and use of health information technology in order to improve health care quality,
increase patient safety, reduce health care costs and improve public health”
(retrieved April 30, 2009 from http://www.health.state.mn.us/ehealth). They have
produced a mandate that calls for an interoperable electronic health record to be
in use by the year 2015, and for electronic prescribing, or e-Prescribing, to be in
place by 2011.
E-prescribing will have the potential to significantly improve patient safety
and reduce the costs associated with errors that may occur due to errors in
medication reconciliation. The mandate calls for any entity involved in prescribing
to do so electronically, while adhering to specified standards. This would directly
affect providers, pharmacies, insurance companies, and patients. The potential
benefits of e-prescribing are clearly stated in Minnesota’s e-Prescribing Mandate
(2008):
“1. To improve the quality, safety, and cost-effectiveness of the entire
prescribing and medication management process
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2. To reduce adverse drug events (ADE’s) costs which are too high in
human and financial terms
3. To reduce [the] burden of callbacks and rework to discuss possible
errors and clarify prescriptions
4. To facilitate access to comprehensive drug information between
outpatient and hospital settings which will reduce ADE’s”.
When patients are admitted to and discharged from the hospital,
omissions or errors have a higher probability of occurring due to inaccurate or
incomplete medication lists (Vira, T. et al., 2006). The importance of a complete
medication list is reinforced by Glintborg, et. al. (2007), whom acknowledge that
errors often occur due to polypharmacy. Patients are often the source of their
own medication history, however their recall abilities are not always one hundred
percent accurate and frequent medication changes can further add to the
problem. If all providers and healthcare systems used an interoperable EHR,
errors in medication reconciliation could be substantially reduced.
Our use case focuses on improving the medication reconciliation process
at discharge by utilizing an EHR for provider order entry. By entering medication
orders directly into the computer, the process is more efficient. The provider will
be able to view the patient’s current medications, select the ones to continue,
and add any new medications to the patient’s discharge list. By using an EHR,
the computer software would automatically check the orders to ensure safe
dosages, appropriate indications, and any potential interactions or
e Health Initiative: Medication Gaps 7
contraindications. The pharmacist would also be reviewing the orders as a
double safety mechanism. This complete list of discharge medications would be
printed off for the patient, and an electronic record would be transmitted to the
patient’s pharmacy, primary clinic, and any other clinic or provider that the patient
visits. By keeping an updated EHR of the patient’s medication list, patient safety
and continuity of care are maintained.
Stakeholders
From the graphs, one can see there are multiple Stakeholders that provide
input in the Discharge Medication Reconciliation process and who would benefit
from simplification of the process. The key Stakeholders are patients & families,
hospital admitting and discharge providers, Primary care providers, nursing,
pharmacy, and community care agencies (i.e. retail pharmacy,
homecare/hospice, and nursing homes).
Each of the stakeholders involved benefits namely through increased
patient safety and improved overall efficiency of the process. This increase in
patient safety and efficiency of workflow is achieved by eliminating multiple paper
and electronic copies of the discharge medication record as well as eliminating
redundant steps in the completion of the discharge medication reconciliation
process. Providers and patients could benefit from the addition of a clinical
decision support tool in this use case. A clinical decision support tool would
assist with some of the consistent medication reconciliation tasks of checking
medication interactions, allergy information, and medication dosing accuracy.
This could also aide in identifying what medications would be covered by the
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patient’s insurance company thus limiting medication changes that happen after
discharge due to formulary differences. Clinical decision support tools could
assist providers in determining appropriate medication dosages based on labs, if
there are any contraindications, and what follow up might be recommended.
Medication orders could be flagged automatically alerting the pharmacy to
contact the physician directly for clarification.
An additional tier of stakeholders includes payer sources (such as a
patient’s insurance company, Medicare, and Medicaid) and healthcare
organizations such as hospitals, clinics, and those who purchase health
information technology products. These stakeholders would hopefully see
financial benefits due to increased patient safety and hopefully decreased repeat
admissions to the hospital. Increased productivity through simplification of
workflow would have a positive financial impact on individual hospitals, clinics
and healthcare organizations.
The final stakeholders involved in this use case would be local, state and
national agencies. The regulatory and governing organizations have the ability to
make interoperability possible locally, and eventually, throughout the state and
nation. Financial incentives or assistance may be necessary to bring individual
clinics, hospitals, and community agencies into the electronic era. Software
developers would also be involved in order to continue evolving current software
to meet ever increasing demands and sophisticated needs of patients and
healthcare providers.
Improved Workflow Process
e Health Initiative: Medication Gaps 9
Our use case process begins at the point where a discharge is considered
by the provider. Because the provider becomes more involved up front in the
discharge process, much of the re-work that is traditionally experienced is
reduced considerably. The provider orders the discharge medications via an
electronic health record or a medication software application. Clinical decision
support embedded within the application warns the provider of allergies,
formulary preferences, improper dosages and duplications. These suggestions
allow the provider to review and consider alternatives quickly and in real-time,
thus streamlining the process.
Once the medications are entered and reviewed by decision support, the
orders are transmitted to the pharmacy which, for safety purposes, cross-checks
for errors that may have been overlooked or unrealized by the decision support
software. The floor charge nurse will subsequently review the discharge
medication list particularly for omissions. The charge RN can then authorize
direct transmission of any outpatient discharge medications directly to the
patient’s preferred pharmacy. At the same time, the patient’s floor RN can then
be authorized to review a printed discharge medication list with the patient for
understanding and education. Upon discharge, the patient will receive an
accurate, updated discharge medication list and, if the technology is available,
their SmartCard would be updated and available for the primary care clinic or
subsequent hospital admission.
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e Health Initiative: Medication Gaps 11
Communication Process
This use care requires communication links between multiple health care
professionals. As previously diagramed, interactions between providers,
pharmacy and the nursing staff are critical for successful outcomes. Our
proposed system would have the ability to provide data to clinics and other
ancillary services. Patients provide either hard-copy lists of medications or enlist
SmartCard technology.
All entities will need to engage information technology experts and the software
used must be interoperable within the system. We envision that all stakeholders
are linked together similar to spokes on a wheel as diagramed below:
e Health Initiative: Medication Gaps 12
Functional Requirements
In an effort to streamline the medication reconciliation process and
improve patient safety, it is important that the system can support our use case.
The system will have to be capable of supporting the following functional
requirements outlined by The Certification Commission for Healthcare
Information Technology (2008):

“The system shall create a single patient record for each patient.” (no. 1)

“The system shall associate (store and link) key identifier information (e.g.,
system ID, medical record number) with each patient record.” (no. 2)

“The system shall capture and maintain demographic information as part
of the patient record.” (no. 8)

“The system shall provide the ability to create and maintain medication
lists.” (no. 22)

“The system shall provide the ability to print a current medication list.” (no.
31)

“The system shall provide the ability to capture and store lists of
medications and other agents to which the patient has had an allergic or
other adverse reaction.” (no. 38)

“The system shall provide the ability to create prescription or other
medication orders with sufficient information for correct filling and
administration by a pharmacy.” (no. 90)

“The system shall provide the ability to check for potential interactions
between medications to be prescribed and current medications and alert
e Health Initiative: Medication Gaps 13
the user at the time of medication ordering if potential interactions exist.”
(no. 160)
A system with these criteria would enable the provider, pharmacy, nurses, and
other people involved in the health care team to work together, using the
electronic health record, to ensure patients are getting their proper medications
upon discharge from the hospital.
Relevant Standards and Universal Terminology
Systematized Nomenclature of Medicine Clinical Terms (SNOMED-CT) is
a “dynamic, scientifically validated clinical healthcare terminology and
infrastructure” (SNOMEDCT: An IHTSDO Product, 2009). It has over 344,000
active concepts, and is a registered standard with HL7. It is maintained by the
College of American Pathologists, and serves to communicate the wide variety of
information in a patient’s medical record (Engelbardt and Nelson, 2002). It has
many different uses, including the electronic health record, monitoring in the
intensive care, clinical decision support, medical research studies, clinical trials,
computerized physician order entry, disease surveillance, image indexing and
consumer health information services. In addition to the completeness of
SNOMED-CT’s database, it also maintains the ability to map terms to current
data systems, therefore limiting repetition in data collection and distribution
(SNOMEDCT: An IHTSDO Product, 2009). It can also cross-map to other
international standards and is already used in more than 50 countries.
SNOMED-CT consists of concepts, descriptions, relationships and
attributes. A concept is the unit of meaning that can be assembled into logical
e Health Initiative: Medication Gaps 14
definitions. A description is a term that names a concept. Each concept has a
fully specified name and a preferred term. Also, it is important to note that a
single concept may have many descriptions, and separate concepts may share
the same description (Konicek, n.d.). Each concept is organized into one of
nineteen distinct hierarchies. These hierarchies are vertical classification
systems, and include titles such as: body structure, clinical finding, environment,
observable entity, and procedure (SNOMED-CT International Release, 2009).
The attributes in SNOMED-CT are the roles that allow links between the
hierarchies to be determined. A relationship is an association between two
concepts, and can either be a linkage of concepts within the same hierarchy, or
allow links across hierarchies (Konicek, n.d.). For the purpose of our use case,
we are focusing mainly on the concept ID to map the terms in our database.
Rules for Mapping Terms
Because of SNOMED-CT’s broad coverage of data elements and its
capacity to map terms to other data bases, the rule for this assignment was to
document the connections between SNOMED-CT’s utilization of codes related to
medications reconciliation and other languages. The overlay of SNOMED-CT’s
demographic elements and all other languages investigated proved to be an
almost seamless fit. All languages also agreed that medications reconciliation
connotes the process of reviewing a patient’s list of prescribed and OTC
medications at admission, discharge, and various transition points-of-care during
an episode of care.
Tables Mapping Local Term from Use Case with Standardized Vocabularies
e Health Initiative: Medication Gaps 15
Table 1. Demographics
Local Term
Definition
From Use
Content
Case
Unique
Code specific
Patient
to patient
Identifier
identification
Last Name
Legal Name
First Name
Legal Name
Middle Initial
Legal Name
Street
Address
City
Physical
Address
City which
patient resides
State which
patient resides
Zip code of
patient’s
residence
Contact
number
State
Zip code
10 Digit
Phone
Number
Date of birth
Primary Care
Provider
Preferred
Pharmacy
Primary
Clinic
MM-DD-YYYY
Health Care
Professional
Pharmacy of
Choice
Clinic of
health care
Vocabulary
Term
Code
Standardized
Vocabulary
Medical
Record
Number
39822500
SNOMED-CT
Patient
Identification
Patient
Identification
Patient
Identification
Environment
184096005
SNOMED-CT
408677003
SNOMED-CT
397742009
SNOMED-CT
397635003
SNOMED-CT
Environment
284560003
SNOMED-CT
Environment
398070004
SNOMED-CT
Environment
SNOMED-CT
Phone number 398198004
SNOMED-CT
Birth date
Medical
Practitioner
Pharmacy
Facility
Health Care
Related
Organization
184099003
158965000
SNOMED-CT
SNOMED-CT
264372000
SNOMED-CT
257585005
SNOMED-CT
Table 2. Medications
Local Term
From Use
Case
Unique
Patient
Identifier
Definition
Content
Vocabulary
Term
Code
Standardized
Vocabulary
Code specific
to patient
identification
Medical Record 39822500
Number
SNOMED-CT
Allergies
Patient’s drug
Hypersensitivity 106190000
SNOMED-CT
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Medication
Name
Medication
Dose
Medication
Route
Medication
Frequency
Start Date
End Date
Final
Discharge
Medication
List
allergies
Prescribed
medication on
discharge
Amount of
medication
PO, SQ, IV,
IM, topical
Times to take
medications
When to
begin
medication
When to stop
medication
Therapeutic
or Preventive
Procedure
Table 3. Discharge
Local Term
Definition
From Use
Content
Case
Final
List generated
discharge
from final
medication
reconciliation
list
process
Pharmaceutical
Preparations
373873005
SNOMED-CT
Quantitative
Concept
Drug
Administration
Routes
Frequencies
(time pattern)
Date
408102007
SNOMED-CT
263513008
SNOMED-CT
272123002
SNOMED-CT
118575009
SNOMED-CT
Date
118575009
SNOMED-CT
Medication
Reconciliation
C2317067
SNOMED-CT
Vocabulary
Term
Code
Standardized
Vocabulary
A3398333/SN
OMED Clinical
Terms/FN/371
754007
SNOMED CT
Discharge
Planning
(procedure)
Project Plan
To transform our use case into an actual project, we have applied the
system development life cycle to guide the process. The Maryland Department
of Information Technology defines the life cycle in nine terms: initiation, concept
development, planning, requirements analysis, design, development, integration,
implementation and maintenance (2008). For the purposes of our project, we will
focus only on six: initiation/concept development, design, development,
implementation, and maintenance.
e Health Initiative: Medication Gaps 17
The initiation phase requires the definition of a need. The current
medication reconciliation process poses a risk to patient safety, wastes
resources, and lacks continuity of care. Our use case has shown the gaps in
care, and where the process can be improved. The workflow could be improved
by utilizing an electronic health record to reconcile discharge medications, and
enhance continuity of care by allowing different providers electronic access to a
patient’s medication history.
Once the problem has been defined, the system must be designed. This
process is usually managed by the information technology department. The
system is either designed to work with current software, or new software is
ordered from a vendor. One vendor that offers high level medication software is
Eclypsis. It has developed Sunrise Medication Management, and one feature of
the software is discharge reconciliation where providers can reconcile discharge
orders by entering both inpatient medications and outpatient prescriptions.
Whether a new system is designed, or one is purchased, the requirements must
be clearly stated and the needs of the system understood. It is critical to involve
the stakeholders and end users in all steps of the process, since they will be
directly involved in using the software once it is implemented. Their workflow
would be observed, and they would be interviewed to gather the most accurate
information related to how the system currently works and how it can be
improved.
After the design phase, development would take place. A vendor would
be selected, and the needs of the system would be communicated to the vendor.
e Health Initiative: Medication Gaps 18
As the software is being developed, it would be tested and retested to ensure it
adheres to the desired specifications. The end users would be involved to offer
input on its efficiency and usability, and to assess if it meets their needs. If
issues arise, they would be corrected to ensure a smoother transition once the
software is implemented.
End user testing and training will be critical during the implementation
phase. As the software is being rolled out, super users would be selected to
assist staff in learning the new system. The end users would be closely involved
with the IT department to troubleshoot any outstanding or new issues. The new
software would be slowly introduced to minimize disruptions to the workflow, and
eventually change over completely.
The maintenance phase is ongoing, and the end users will be
continuously interviewed and observed interacting with the new system. There
may still be changes made to correct any inefficiencies and ensure that the final
product meets the goals set forth by the initial concept.
Due to the wide variety of different software programs available, one of the
greatest challenges will be maintaining interoperability between inpatient and
outpatient settings that may utilize different software programs. An idea our use
case briefly explored was the development of a SmartCard technology that would
save the patient’s medication list and be able to be read at any clinic, pharmacy,
or hospital. This would require extensive software development, and would be
an entirely new use case to examine.
Reflection
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Research demonstrates that an effective medication reconciliation process
is instrumental in reducing and preventing medication errors. This paper
exemplifies areas for improvement in this process. A system to promote
comparison of what medications patients are taking and being prescribed in
different settings could decrease multiple adverse events. Examples of these
adverse events would be errors of omission, drug-drug interactions, drug-disease
interactions and other discrepancies.
By having a card to update the records for comparison, this will increase
provider efficiency and clear communication between various healthcare
organizations--ultimately increase patient safety!
The proposed electronic system and workflow would be less convoluted
and cleaner than the current process in place at this hospital. There would be an
electronic copy of the medication list available for review by providers involved in
follow up care of the patient. It would also limit needing to rewrite a handwritten
version of the medication list for patients. Being that this current hospital has a
portion of the medication reconciliation process in and EHR it seems very
feasible to implement this proposal.
The feasibility of implementing this process at various other healthcare
settings would involve applying the system life cycle process to each individual
setting. Additional development is needed to meet the long term goal of
synchronizing all healthcare facilities to be equipped with technology for patients
to have a SmartCard or electronic version of their medication list that can be
e Health Initiative: Medication Gaps 20
accessed by all healthcare personal regardless of the specific EHR software
program in place at the facility.
Collaboration between multiple and often competing health systems will
be required to achieve optimal discharge medication reconciliation. This may be
more feasible to achieve within a large health system with multiple clinics and
hospitals under one umbrella and clinical information system. It would be
necessary and possibly challenging to garner support from smaller provider and
specialty groups that still operate with paper documentation or on isolated clinical
information systems (EHR’s). It will be especially important to get “buy in” from
providers who may already feel over burdened and that an EHR places
undesirable added requirements on the provider.
Interoperability among various clinical information systems and paper
documentation processes could take months and likely years to achieve.
Financial investments will be required and incentives may be necessary to
motivate multiple organizations to implement the required software to achieve
interoperability. Perhaps regulatory requirements and standards would provide
additional incentives and feasibility for large scale adoption of an electronically
based discharge medication reconciliation process.
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Contributors to the proposal:
This eHealth proposal was a joint effort discussed from January to May 2009 by
N5115 Group 2. For purposes of writing the proposal the Questions were divided
up as follows with all members providing additional feedback, input, and editing
during the course of the semester.
Questions 1 & 3
Question 2
Questions 4 & 10
Questions 5 & 11
Questions 6 & 7
Questions 8 & 9
Denise Frederick
Susan Strohschein
Andrea Szkarlat
Jolene Dickerman
Chris Pensinger
Thomas Lewison
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References
A Prescription for Meeting Minnesota’s 2015 Interoperable Electronic Health
Record Mandate. A Statewide Implementation Plan. (June 2008) Retrieved April
10, 2009 from: http://www.health.state.mn.us/ehealth/ehrplan2008.pdf
Maryland Department of Information Technology: System Development Life
Cycle (SDLC), Volume 1. (2008). Retrieved April 14, 2009 from:
http://doit.maryland.gov/policies/Documents/sdlc/sdlcvol1.pdf
International Health Terminology Standards Development Organization. (2009).
About SNOMED-CT. Retrieved April 12, 2009 from:
http://www.ihtsdo.org/snomed-ct/snomed-ct0/
Barnsteiner J. Chapter 38: Medication reconciliation in Hughes RG (ed.) Patient
safety and quality: An evidence-based handbook for nurses. Volume 2 (Prepared
with support from the Robert Wood Johnson Foundation.) AHRQ Publication No.
08-0043. Rockville, MD: Agency for Healthcare Research and Quality; April
2008; p 2-459
The Certification Commission for Healthcare Information Technology (2007).
AmbulatoryFunctionality 2007 Final Criteria-March 16, 2007. Retrieved April 30,
2009
from:http://www.cchit.org/files/Ambulatory_Domain/CCHIT_Ambulatory_FUNCTI
ONALITY_Criteria_2007_Final_16Mar07.pdf.
Engelbardt & Nelson. Healthcare Informatics: An Interdisciplinary Approach.
Mosby, St. Louis, MO. 2002. Vira, T. et al. (2006).
Reconcilable differences: correcting medication errors at hospital admission and
discharge. Quality and Safety in Health Care: 15(2):122-126.
Glintborg, B. et al. (2007). Insufficient communication about medication use at the
interface between hospital and primary care. Quality and Safety in Healthcare: 16(1):3439.
Konicek, Debra. (n.d.) SNOMED CT: A Standard Terminology for Healthcare.
Retrieved March 13, 2009 from https://umconnect.umn.edu/p87218168
Minnesota’s e-Prescribing Mandate. (2008). Minnesota Department of Health Fact Sheet.
Retrieved April 30, 2009 from
http://www.health.state.mn.us/ehealth/eprescribing/erxfactsheet08.pdf
Minnesota e-health initiative. Retrieved April 30, 2009 from
http://www.health.state.mn.us/ehealth
e Health Initiative: Medication Gaps 23
Eclypsis: Sunrise Medication Management. Retrieved May 3, 2009 from
http://www.eclipsys.com/solutions/MedicationManagement.asp