A Statewide Medication Management System: Health Information Exchange to Support Drug Therapy Optimization by Pharmacists across the Continuum of Care

Measuring health professionals' perceptions of communication contributing to medication incidents in hospitals - scale development and primary results of weekly perceived communication challenges

BACKGROUND

Communication challenges are one of the main contributors for medication incidents in hospitals, but health professionals' perceptions about variety of the contributing communication factors and the factors' occurrence frequencies are studied little. This cross-sectional descriptive study aimed to (1) operationalize a literature-based framework into a scale for measuring health professionals' perceptions of communication factors, which contribute to medication incidents either directly or indirectly in hospitals, (2) to measure the construct validity and internal consistency of the scale and (3) to describe the primary results of the measured weekly perceived communication challenges.

METHODS

The structured online questionnaire with 82 communication related items was developed based on a framework in literature. A content validity index of expert panelists' answers was used for item reduction. Data was collected between November 1st, 2019, and January 31st, 2020, by convenience sampling. The study sample (n = 303) included multiple health professional groups in diverse specialties, unit types and organizational levels in two specialized university hospital districts in Finland. Exploratory factor analysis with Maximum Likelihood method and Oblique rotation produced a six factors scale consisting of 57 items and having acceptable construct validity and internal consistency.

RESULTS

The six communication factors contributing to medication incidents concerned (1) medication prescriptions, (2) guidelines and reporting, (3) patient and family, (4) guideline implementation,5) competencies and responsibilities, and 6) attitude and atmosphere. The most frequently perceived communication challenges belonged to the Medication prescription related factor. Detailed item frequencies suggested that the most usual weekly challenges were: (1) lack or unclarity of communication about medication prescriptions, (2) missing the prescriptions which were written outside of the regular physician-ward-rounds and (3) digital software restricting information transfer.

CONCLUSIONS

The scale can be used for determining the most frequent detailed communication challenges. Confirmatory factor analysis of the scale is needed with a new sample for the scale validation. The weekly perceived communication challenges suggest that interventions are needed to standardize prescribing documentation and to strengthen communication about prescriptions given outside of regular ward-rounds.

Transforming Health Data to Actionable Information: Recent Progress and Future Opportunities in Health Information Exchange

OBJECTIVES

Provide a systematic review of literature pertaining to health information exchange (HIE) since 2018. Summarize HIE-associated literature for most frequently occurring topics, as well as within the context of the COVID-19 pandemic and health equity. Finally, provide recommendations for how HIE can advance the vision of a digital healthcare ecosystem.

METHODS

A computer program was developed to mediate a literature search of primary literature indexed in MEDLINE that was: (1) indexed with "Health Information Exchange" MeSH descriptor as a major topic; and (2) published between January 2018 and December 2021. Frequency of MeSH descriptors was then used to identify and to rank topics associated with the retrieved literature. COVID-19 literature was identified using the general COVID-19 PubMed Clinical Query filter. Health equity literature was identified using additional MeSH descriptor-based searches. The retrieved literature was then reviewed and summarized.

RESULTS

A total of 256 articles were retrieved and reviewed for this survey. The major thematic areas summarized were: (1) Information Dissemination; (2) Delivery of Health Care; (3) Hospitals; (4) Hospital Emergency Service; (5) COVID-19; (6) Health Disparities; and (7) Computer Security and Confidentiality. A common theme across all areas examined for this survey was the maturity of HIE to support data-driven healthcare delivery. Recommendations were developed based on opportunities identified across the reviewed literature.

CONCLUSIONS

HIE is an essential advance in next generation healthcare delivery. The review of the recent literature (2018-2021) indicates that successful HIE improves healthcare delivery, often resulting in improved health outcomes. There remain major opportunities for expanded use of HIE, including the active engagement of clinical and patient stakeholders. The maturity of HIE reflects the maturity of the biomedical informatics and health data science fields.

Personal Electronic Records of Medications (PERMs) for medication reconciliation at care transitions: a rapid realist review

Background

Medication reconciliation (MedRec), a process to reduce medication error at care transitions, is labour- and resource-intensive and time-consuming. Use of Personal Electronic Records of Medications (PERMs) in health information systems to support MedRec have proven challenging. Relatively little is known about the design, use or implementation of PERMs at care transitions that impacts on MedRec in the ‘real world’. To respond to this gap in knowledge we undertook a rapid realist review (RRR). The aim was to develop theories to explain how, why, when, where and for whom PERMs are designed, implemented or used in practice at care transitions that impacts on MedRec.

Methodology

We used realist methodology and undertook the RRR between August 2020 and February 2021. We collaborated with experts in the field to identify key themes. Articles were sourced from four databases (Pubmed, Embase, CINAHL Complete and OpenGrey) to contribute to the theory development. Quality assessment, screening and data extraction using NVivo was completed. Contexts, mechanisms and outcomes configurations were identified and synthesised. The experts considered these theories for relevance and practicality and suggested refinements.

Results

Ten provisional theories were identified from 19 articles. Some theories relate to the design (T2 Inclusive design, T3 PERMs complement existing good processes, T7 Interoperability), some relate to the implementation (T5 Tailored training, T9 Positive impact of legislation or governance), some relate to use (T6 Support and on-demand training) and others relate iteratively to all stages of the process (T1 Engage stakeholders, T4 Build trust, T8 Resource investment, T10 Patients as users of PERMs).

Conclusions

This RRR has allowed additional valuable data to be extracted from existing primary research, with minimal resources, that may impact positively on future developments in this area. The theories are interdependent to a greater or lesser extent; several or all of the theories may need to be in play to collectively impact on the design, implementation or use of PERMs for MedRec at care transitions. These theories should now be incorporated into an intervention and evaluated to further test their validity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-021-01659-8.

The Optimizing Care Model: Final findings of a novel community pharmacy practice model to enhance patient care delivery using technician product verification

BACKGROUND

The community pharmacy represents a convenient health care access point for patients and is increasingly used to deliver direct patient care services; however, several barriers exist that hinder widespread patient service implementation and scalability. Such barriers include scope of practice restrictions, a dearth of sustainable payment models, lack of pharmacist capacity given other responsibilities, and workflow models developed for dispensing medications rather than clinical care. In an effort to overcome the lack of pharmacist time and capacity, further task delegation to pharmacy technicians has been suggested.

OBJECTIVES

The primary objective of this study was to present the final outcomes of the Optimizing Care Model's impact. The model's impact on pharmacist patient care, workday composition, and rates of product selection errors not identified during final product verification are reported.

METHODS

The Optimizing Care Model is an innovative approach to community pharmacy practice aiming to foster a new patient-centered care delivery model that expands clinical service delivery and fosters collaboration across health care settings through task delegation, primarily through technician product verification (TPV). To investigate the impact of its sustained implementation, a quasi-experimental, 1-group pretest-posttest design was used. Outcomes assessed included medication errors, clinical activities, and workday composition.

RESULTS

Six chain and 3 independent pharmacies completed the final, continuation phase of the study. Overall pharmacist time spent delivering patient care services increased significantly upon implementation of the Optimizing Care Model (21% vs. 43%; P < 0.05), whereas pharmacist time spent performing dispensing-related activities decreased significantly (67% vs. 37%; P < 0.05). Total undetected error rates were significantly less in the Optimizing Care Model phase compared with the traditional model (0.05% vs. 0.01%; P < 0.001).

CONCLUSION

This study presented the final results of a 2-year assessment of the Optimizing Care Model. Results reaffirmed initial published findings that the model and its use of TPV increase the array and frequency of direct patient care services rendered while resulting in lower undetected error rates. Final project results of the Optimizing Care Model demonstrate increased clinical service delivery versus the traditional model, while also improving patient safety with lower rates of undetected dispensing errors within the Optimizing Care Model. The Optimizing Care Model continues to show promise as a future practice model for community pharmacies.

Interdisciplinary Care Networks in Rehabilitation Care for Patients with Chronic Musculoskeletal Pain: A Systematic Review

This systematic review aims to identify what rehabilitation care networks, within primary care or between primary and other health care settings, have been described for patients with chronic musculoskeletal pain, and what their impact is on the Quadruple Aim outcomes (health; health care costs; quality of care experienced by patients; work satisfaction for health care professionals). Studies published between 1 January 1994 and 11 April 2019 were identified in PubMed, CINAHL, Web of Science, and PsycInfo. Forty-nine articles represented 34 interventions: 21 within primary care; 6 between primary and secondary/tertiary care; 1 in primary care and between primary and secondary/tertiary care; 2 between primary and social care; 2 between primary, secondary/tertiary, and social care; and 2 between primary and community care. Results on impact were presented in 19 randomized trials, 12 non-randomized studies, and seven qualitative studies. In conclusion, there is a wide variety of content, collaboration, and evaluation methods of interventions. It seems that patient-centered interdisciplinary interventions are more effective than usual care. Further initiatives should be performed for interdisciplinary interventions within and across health care settings and evaluated with mixed methods on all Quadruple Aim outcomes.

Accuracy of an Electronic Health Record Patient Linkage Module Evaluated between Neighboring Academic Health Care Centers

BACKGROUND

Patients often seek medical treatment among different health care organizations, which can lead to redundant tests and treatments. One electronic health record (EHR) platform, Epic Systems, uses a patient linkage tool called Care Everywhere (CE), to match patients across institutions. To the extent that such linkages accurately identify shared patients across organizations, they would hold potential for improving care.

OBJECTIVE

This study aimed to understand how accurate the CE tool with default settings is to identify identical patients between two neighboring academic health care systems in Southern California, The University of California Los Angeles (UCLA) and Cedars-Sinai Medical Center.

METHODS

We studied CE patient linkage queries received at UCLA from Cedars-Sinai between November 1, 2016, and April 30, 2017. We constructed datasets comprised of linkages ("successful" queries), as well as nonlinkages ("unsuccessful" queries) during this time period. To identify false positive linkages, we screened the "successful" linkages for potential errors and then manually reviewed all that screened positive. To identify false-negative linkages, we applied our own patient matching algorithm to the "unsuccessful" queries and then manually reviewed a sample to identify missed patient linkages.

RESULTS

During the 6-month study period, Cedars-Sinai attempted to link 181,567 unique patient identities to records at UCLA. CE made 22,923 "successful" linkages and returned 158,644 "unsuccessful" queries among these patients. Manual review of the screened "successful" linkages between the two institutions determined there were no false positives. Manual review of a sample of the "unsuccessful" queries (n = 623), demonstrated an extrapolated false-negative rate of 2.97% (95% confidence interval [CI]: 1.6-4.4%).

CONCLUSION

We found that CE provided very reliable patient matching across institutions. The system missed a few linkages, but the false-negative rate was low and there were no false-positive matches over 6 months of use between two nearby institutions.

A qualitative exploration of the experiences of doctors, nurses and pharmacists regarding medication management in outpatient setting

AIM

To understand how the medications are managed by the multidisciplinary team and their suggestions for nursing management, and to develop a framework for safe medication management in hospital-based outpatient.

BACKGROUND

More than 80% of hospital-based outpatient visits involve medication prescriptions, indicating the importance of safe medication management there.

METHODS

This was a qualitative study with face-to-face interviews with physicians, nurses and pharmacists from 11 medical outpatient units.

RESULTS

Four themes elicited were categorized as follows: unclear professional roles and functions in outpatient medication management; intertwined communications; moving from data to wisdom; and ambiguous culture of safety. The resulting model is a collaboration of physicians, nurses, pharmacists, and patients and families integrated with hospital administrative support and information technology in a culture of safety.

CONCLUSIONS

Medication management in outpatient is critical but usually overlooked. Nursing leaders should develop a culture of safety and provide more support and training for nurses to provide comprehensive medication management for outpatients.

IMPLICATIONS FOR NURSING MANAGEMENT

It is important to develop outpatient nurses' role and competence in managing patient medication safety. Nurses in management would benefit from applying the 'framework of efficient and safe medication management for outpatients' to assess and identify weak areas for improvement.

Interruptions in community pharmacies: Frequency, sources, and mitigation strategies

BACKGROUND

Interruptions constitute a key part of the communication strategy for healthcare providers, including community pharmacy personnel. Previous research in other healthcare environments has shown that interruptions are very common and may present as patient safety hazards. One 1999 study, conducted in community pharmacy settings, found that interruptions were prevalent and associated with dispensing errors. In the last 20 years, pharmacies have expanded patient services and implemented new technology. Yet, it is unknown how these changes have affected interruption sources and frequency.

OBJECTIVE

The objective was to characterize the frequency and sources of pharmacist task interruptions that occur in community pharmacies.

METHODS

A cross-sectional qualitative study design was used to evaluate the frequency and sources of pharmacist task interruptions in Wisconsin community pharmacies. The participants included 9 pharmacists and 9 technicians working in 2 independently-owned, 2 mass merchandise, and 2 hospital/clinical-affiliated pharmacies.

RESULTS

Interruption rates ranged from 3 to 7 per hour across the 6 pharmacies. Sources of interruptions included: patients, technicians, self-initiated interruptions, technology used in the pharmacy, and a second pharmacist.

CONCLUSIONS

Interruptions are common in community pharmacies and the causes are multifactorial. Prudent management of interruptions in these work environments may involve improved technician training and better designs of pharmacy technology.

Community-acquired and hospital-acquired medication harm among older inpatients and impact of a state-wide medication management intervention

Background

We previously reported reduction in the rate of hospitalisations with medication harm among older adults with our ‘Pharm2Pharm’ intervention, a pharmacist-led care transition and care coordination model focused on best practices in medication management. The objectives of the current study are to determine the extent to which medication harm among older inpatients is ‘community acquired’ versus ‘hospital acquired’ and to assess the effectiveness of the Pharm2Pharm model with each type.

Methods

After a 3-year baseline, six non-federal general acute care hospitals with 50 or more beds in Hawaii implemented Pharm2Pharm sequentially. The other five such hospitals served as the comparison group. We measured frequencies and quarterly rates of admissions among those aged 65 and older with ‘community-acquired’ (International Classification of Diseases-coded as present on admission) and ‘hospital-acquired’ (coded as not present on admission) medication harm per 1000 admissions from 2010 to 2014.

Results

There were 189 078 total admissions from 2010 through 2014, 7% of which had one or more medication harm codes. There were 16 225 medication harm codes, 70% of which were community-acquired, among these 13 795 admissions. The varied times when the intervention was implemented across hospitals were associated with a significant reduction in the rate of admissions with community-acquired medication harm compared with non-intervention hospitals (p=0.001), and specifically harm by anticoagulants (p<0.0001) and by medications in therapeutic use (p<0.001). The hospital-acquired medication harm rate did not change. The rate of admissions with community-acquired medication harm was reduced by 4.28 admissions per 1000 admissions per quarter in the Pharm2Pharm hospitals relative to the comparison hospitals.

Conclusion

The Pharm2Pharm model is an effective way to address the growing problem of community-acquired medication harm among high-risk, chronically ill patients. This model demonstrates the importance of deploying specially trained pharmacists in the hospital and in the community to systematically identify and resolve drug therapy problems.