Medication Review Skill

Perform comprehensive medication reconciliation, interaction checking, and adherence assessment. Designed to support clinical decision-making and patient safety.

Overview

This skill enables clinical AI agents to:

• Reconcile medication lists across care settings
• Detect drug-drug and drug-disease interactions
• Assess contraindications and allergies
• Score adherence probability
• Evaluate polypharmacy risk
• Generate medication summaries for patients and providers

Medication Reconciliation

Data Collection

Gather medication information from:

• Patient self-report (current medications)
• Prescription records
• Hospital discharge summaries
• Pharmacy fill history
• Over-the-counter medications
• Supplements and herbal products

Reconciliation Steps

1. List All Medications - Create comprehensive current medication list
2. Compare Sources - Identify discrepancies between sources
3. Verify with Patient - Confirm actual usage patterns
4. Resolve Discrepancies - Document intentional vs unintentional differences
5. Update Record - Create reconciled medication list

Discrepancy Categories

| Type | Description | Example | |------|-------------|---------| | Omission | Medication on record not being taken | Patient stopped ACE inhibitor | | Commission | Patient taking medication not on record | Added OTC NSAIDs | | Dose Discrepancy | Different dose than prescribed | Taking 20mg instead of 40mg | | Frequency Discrepancy | Different schedule than prescribed | Taking once daily instead of BID | | Duplication | Same drug class from multiple sources | Two different statins |

Drug Interaction Checking

Interaction Severity Levels

| Level | Description | Action | |-------|-------------|--------| | CONTRAINDICATED | Combination should never be used | Alert clinician, do not proceed | | MAJOR | May cause serious harm | Clinician review required | | MODERATE | May require monitoring or adjustment | Document and monitor | | MINOR | Minimal clinical significance | Informational alert |

Common High-Risk Interactions

Anticoagulants:

• Warfarin + NSAIDs → Increased bleeding risk
• DOACs + Azole antifungals → Increased DOAC levels
• Aspirin + Anticoagulants → Additive bleeding risk

Cardiovascular:

• Beta-blockers + Non-DHP CCBs → Bradycardia, heart block
• ACE inhibitors + K-sparing diuretics → Hyperkalemia
• Digoxin + Amiodarone → Digoxin toxicity

Mental Health:

• MAOIs + SSRIs → Serotonin syndrome (CONTRAINDICATED)
• SSRIs + Triptans → Serotonin syndrome risk
• Benzodiazepines + Opioids → Respiratory depression

Metabolic:

• Sulfonylureas + Fluoroquinolones → Hypoglycemia
• Metformin + Contrast dye → Lactic acidosis risk
• Levothyroxine + Calcium/Iron → Reduced absorption

Interaction Checking Process

1. Input all active medications
2. Cross-reference each pair for interactions
3. Check against patient conditions (drug-disease)
4. Verify allergy/adverse reaction history
5. Generate interaction report with severity rankings

Contraindication Detection

Allergy Assessment

Document and verify:

• Drug allergies with reaction type
• Drug intolerances (non-allergic adverse effects)
• Cross-reactivity potential (e.g., penicillin/cephalosporin)
• Severity of previous reactions

Drug-Disease Contraindications

| Medication Class | Contraindicated Conditions | |-----------------|---------------------------| | NSAIDs | GI bleeding, CKD stage 4+, heart failure | | Metformin | eGFR <30, acute kidney injury | | Beta-blockers | Severe bradycardia, uncompensated heart failure | | ACE inhibitors | Angioedema history, pregnancy | | Fluoroquinolones | Tendon disorders, myasthenia gravis |

Adherence Assessment

Adherence Probability Scoring

Evaluate factors affecting medication adherence:

Patient Factors:

• Health literacy level
• Understanding of condition
• Motivation and self-efficacy
• Cognitive function
• Manual dexterity

Medication Factors:

• Number of medications (polypharmacy burden)
• Dosing frequency complexity
• Side effect profile
• Cost/insurance coverage
• Formulation (pill size, taste)

System Factors:

• Access to pharmacy
• Provider communication
• Follow-up frequency
• Social support

Adherence Score Interpretation

| Score | Risk Level | Intervention | |-------|-----------|--------------| | 80-100% | Low risk | Standard follow-up | | 60-79% | Moderate risk | Adherence counseling, simplify regimen | | 40-59% | High risk | Intensive intervention, pill boxes, reminders | | <40% | Very high risk | Care coordination, social work involvement |

Polypharmacy Risk Assessment

Definition

Polypharmacy: 5+ chronic medications Hyper-polypharmacy: 10+ chronic medications

Risk Evaluation

Prescribing Cascade Risk:

• Medication A causes side effect
• Side effect treated with Medication B
• Creates unnecessary complexity

Deprescribing Opportunities:

• Identify medications that may be discontinued
• Assess risk-benefit for each medication
• Prioritize high-risk, low-benefit medications

Beers Criteria Application

For patients ≥65 years, screen for potentially inappropriate medications:

High-Risk Categories:

• Anticholinergics with cognitive effects
• Benzodiazepines (fall risk, cognitive)
• Proton pump inhibitors (long-term)
• First-generation antihistamines
• Muscle relaxants

Medication Summary Generation

Patient-Friendly Medication List

Generate readable medication summaries:

MY MEDICATIONS

1. Metformin 500mg
   - Take: 1 tablet twice daily with meals
   - For: Blood sugar control (diabetes)
   - Important: Take with food to reduce stomach upset

2. Lisinopril 10mg
   - Take: 1 tablet once daily
   - For: Blood pressure and kidney protection
   - Important: Report any swelling of face or lips

3. Atorvastatin 20mg
   - Take: 1 tablet at bedtime
   - For: Cholesterol control
   - Important: Report any muscle pain or weakness

ALLERGIES: Penicillin (rash)

Last Updated: [Date]

Provider Medication Summary

MEDICATION RECONCILIATION SUMMARY

Active Medications: 8
Polypharmacy Status: Yes (moderate complexity)
Adherence Risk: Moderate (65%)

INTERACTION ALERTS:
⚠️ MODERATE: Lisinopril + Spironolactone - Monitor potassium
⚠️ MINOR: Atorvastatin + Amlodipine - May increase statin levels

CONTRAINDICATIONS CHECKED: None identified

ADHERENCE BARRIERS:
- Complex regimen (3 different dosing times)
- Cost concern for brand-name medication
- Occasional missed doses when traveling

RECOMMENDATIONS:
1. Consider consolidating dosing times
2. Discuss generic alternatives for cost
3. Provide pill organizer

Usage Instructions

1. Gather Medication Data

Collect from all sources:

• Current prescription list
• Patient interview
• Pharmacy records if available
• Recent hospital/specialist records

2. Perform Reconciliation

• Create unified medication list
• Note discrepancies and reasons
• Verify adherence patterns
• Document allergies and intolerances

3. Run Interaction Analysis

• Check all pairwise drug interactions
• Assess drug-disease contraindications
• Verify allergy cross-reactivity
• Generate severity-ranked alert list

4. Calculate Risk Scores

• Adherence probability
• Polypharmacy burden
• Beers criteria flags (if applicable)
• Deprescribing candidates

5. Generate Documentation

• Patient medication card
• Provider summary
• Interaction report
• Recommendations for optimization

Scope Limitations

This skill does NOT:

• Replace pharmacist clinical judgment
• Provide dosing recommendations for specific patients
• Guarantee detection of all interactions
• Account for genetic pharmacokinetic variations
• Serve as definitive prescribing guidance

All findings require clinician review before action.

Integration with TherapyPod

This skill integrates with:

• Treatment Plans - Medication sections of treatment plans
• Patient Education - Medication teaching materials
• Care Coordination - Handoff medication reconciliation
• ClinEval Benchmark - Clinical accuracy validation

Data Sources

Interaction and contraindication data derived from:

• FDA drug labeling
• Clinical Pharmacology databases
• Published literature
• Professional guidelines

References

• See references/drug-interactions.md for common interaction pairs
• See references/beers-criteria.md for geriatric considerations
• See references/adherence-interventions.md for improvement strategies