Electronic tools to support medication reconciliation: a systematic review

Patient Perspectives on a Digital Assistant for Medication Reconciliation: An Interview Study Comparing Socioeconomic Groups

Medication reconciliation, the process of documenting a patient's medication, is currently a time-consuming and labor-intensive process. To make medication reconciliation more efficient, digital assistants (DAs) offer a promising solution. Especially since human-like digital interfaces tend to be appreciated by more vulnerable populations such as patients in a low socioeconomic position (SEP). Despite the potential of DAs for low-SEP populations in particular, these groups are often not involved during the development and design phase of such digital health interventions. This exclusion may explain the lower adoption rates of digital interventions among low-SEP patients and exacerbate the so-called digital divide. We explored the perceptions and needs of patients across the SEP gradient using a participatory design approach. Patients of low-, middle-, and high-SEP backgrounds were asked to interact with a DA developed for this study and were interviewed afterward. A thematic analysis revealed seven themes regarding design, input method, comprehensibility, privacy concerns, benefits, the intention to use, and reassurance. Overall, patients were afraid to make mistakes in their medication entries and therefore valued feedback from the system or caregivers. Low-SEP patients specifically seemed to value more structured input methods when using the DA, while high-SEP patients emphasized the importance of a secure environment for the DA and sought clarity about its functionalities. Our study demonstrates the importance of involving patients across the socioeconomic gradient when developing a digital health tool and offers concrete recommendations for inclusive DA design for researchers and developers.

A national survey on assessment of knowledge, perceptions, practice, and barriers among hospital pharmacists towards medication reconciliation in United Arab Emirates

Medication reconciliation (MedRec) helps prevent medication errors. This cross-sectional, nationwide study assessed the knowledge, perceptions, practice, and barriers toward MedRec amongst hospital pharmacy practitioners in the United Arab Emirates. A total of 342 conveniently chosen stratified hospital pharmacists responded to the online survey (88.6% response rate). Mann-Whitney U test and Kruskal-Wallis test were applied at alpha = 0.05 and post hoc analysis was performed using Bonferroni test. The overall median knowledge score was 9/12 with IQR (9-11) with higher levels among clinical pharmacists (p < 0.001) and previously trained pharmacists (p < 0.001). Of the respondents, 35.09% (n = 120) practiced MedRec for fewer than five patients per week despite having a strong perception of their role in this process. The overall median perception score was 32.5/35 IQR (28-35) with higher scores among clinical pharmacists (p < 0.001) and those who attended previous training or workshops (p < 0.001). The median barrier score was 24/30 with an IQR (21-25), where lack of training and knowledge were the most common barriers. Results showed that pharmacists who did not attend previous training or workshops on MedRec had higher barrier levels than those who attended (p = 0.012). This study emphasizes the significance of tackling knowledge gaps, aligning perceptions with practice, and suggesting educational interventions.

Improving Accuracy of Medication Reconciliation for Hospitalized Children: A Quality Project

BACKGROUND AND OBJECTIVES

Medication reconciliation is a complex, but necessary, process to prevent patient harm from medication discrepancies. Locally, the steps of medication reconciliation are completed consistently; however, medication errors still occur, which suggest process inaccuracies. We focused on removal of unnecessary medications as a proxy for accuracy. The primary aim was to increase the percentage of patients admitted to the pediatric hospital medicine service with at least 1 medication removed from the home medication list by 10% during the hospital stay by June of 2022.

METHODS

Using the Model for Improvement, a multidisciplinary team was formed at a children's hospital, a survey was completed, and multiple Plan-Do-Study-Act cycles were done focusing on: 1. simplifying electronic health record processes by making it easier to remove medications; 2. continuous resident education about the electronic health record processes to improve efficiency and address knowledge gaps; and 3. auditing charts and real-time feedback. Data were monitored with statistical process control charts.

RESULTS

The project exceeded the goal, improving from 35% to 48% of patients having at least 1 medication removed from their home medication list. Improvement has sustained for 12 months.

CONCLUSIONS

The combination of interventions including simplifying workflow, improving education, and enhancing accountability resulted in more patients with medications removed from their home medication list.

Understanding the Information Needs of Pharmacy Staff Using CancelRx: A Qualitative Study of the Use of Prescription E-cancellation

Background

Although electronic prescription cancellation such as via CancelRx can facilitate critical communication between prescribers and pharmacy staff about discontinued medications, there is little work that explores whether CancelRx meets the needs of pharmacy staff users.

Objective

This study leverages qualitative interviews with pharmacy staff to address the following question: When medication changes are made by a prescriber using CancelRx, what information is needed by pharmacy staff to make correct and effective decisions in their roles in medication management?

Methods

We conducted an inductive thematic analysis of interviews with 11 pharmacy staff members (pharmacists and pharmacy technicians) across three outpatient community pharmacy sites within an academic health care system.

Results

Three information needs themes were consistently identified by both pharmacists and pharmacy technicians: prescriber intent when initiating the CancelRx, clinical rationale for the medication change, and intended medication regimen. Notably, both pharmacists and pharmacy technicians often reported seeking multiple information needs not fully addressed by CancelRx in the electronic health record (EHR) to achieve the shared goals of correct dispensing of medications and supporting patient self-management.

Conclusions

Our qualitative analysis reveals that outpatient community pharmacy staff in an academic health care system often seek additional information from the (EHR) following medication changes communicated by CancelRx to meet their information needs. Ideally, the prescriber would provide sufficient information through CancelRx to automatically identify all discontinued prescriptions. These limitations highlight the need for design features that support routine communication of needed information at the time of a medication change, such as structured data elements.

Electronic health record intervention to increase use of NSAIDs as analgesia for hospitalised patients: a cluster randomised controlled study

BACKGROUND

Prescribing non-opioid pain medications, such as non-steroidal anti-inflammatory (NSAIDs) medications, has been shown to reduce pain and decrease opioid use, but it is unclear how to effectively encourage multimodal pain medication prescribing for hospitalised patients. Therefore, the aim of this study is to evaluate the effect of prechecking non-opioid pain medication orders on clinician prescribing of NSAIDs among hospitalised adults.

METHODS

This was a cluster randomised controlled trial of adult (≥18 years) hospitalised patients admitted to three hospital sites under one quaternary hospital system in the USA from 2 March 2022 to 3 March 2023. A multimodal pain order panel was embedded in the admission order set, with NSAIDs prechecked in the intervention group. The intervention group could uncheck the NSAID order. The control group had access to the same NSAID order. The primary outcome was an increase in NSAID ordering. Secondary outcomes include NSAID administration, inpatient pain scores and opioid use and prescribing and relevant clinical harms including acute kidney injury, new gastrointestinal bleed and in-hospital death.

RESULTS

Overall, 1049 clinicians were randomised. The study included 6239 patients for a total of 9595 encounters. Both NSAID ordering (36 vs 43%, p<0.001) and administering (30 vs 34%, p=0.001) by the end of the first full hospital day were higher in the intervention (prechecked) group. There was no statistically significant difference in opioid outcomes during the hospitalisation and at discharge. There was a statistically but perhaps not clinically significant difference in pain scores during both the first and last full hospital day.

CONCLUSIONS

This cluster randomised controlled trial showed that prechecking an order for NSAIDs to promote multimodal pain management in the admission order set increased NSAID ordering and administration, although there were no changes to pain scores or opioid use. While prechecking orders is an important way to increase adoption, safety checks should be in place.

A behavioral intervention to promote use of multimodal pain medication for hospitalized patients: A randomized controlled trial

BACKGROUND

The use of nonsteroidal anti-inflammatory drugs (NSAIDs) can reduce pain and has become a core strategy to decrease opioid use, but there is a lack of data to describe encouraging use when admitting patients using electronic health record systems.

OBJECTIVE

Assess an electronic health record system to increase ordering of NSAIDs for hospitalized adults.

DESIGNS, SETTINGS AND PARTICIPANTS

We performed a cluster randomized controlled trial of clinicians admitting adult patients to a health system over a 9-month period. Clinicians were randomized to use a standard admission order set.

INTERVENTION

Clinicians in the intervention arm were required to actively order or decline NSAIDs; the control arm was shown the same order but without a required response.

MAIN OUTCOME AND MEASURES

The primary outcome was NSAIDs ordered and administered by the first full hospital day. Secondary outcomes included pain scores and opioid prescribing.

RESULTS

A total of 20,085 hospitalizations were included. Among these hospitalizations, patients had a mean age of 58 years, and a Charlson comorbidity score of 2.97, while 50% and 56% were female and White, respectively. Overall, 52% were admitted by a clinician randomized to the intervention arm. NSAIDs were ordered in 2267 (22%) interventions and 2093 (22%) control admissions (p = .10). Similarly, there were no statistical differences in NSAID administration, pain scores, or opioid prescribing. Average pain scores (0-5 scale) were 3.36 in the control group and 3.39 in the intervention group (p = .46). There were no differences in clinical harms.

CONCLUSIONS AND RELEVANCE

Requiring an active decision to order an NSAID at admission had no demonstrable impact on NSAID ordering. Multicomponent interventions, perhaps with stronger decision support, may be necessary to encourage NSAID ordering.

Antiparkinsonian Medication Reconciliation as a Strategy to Improve Safety by Preventing Medication Errors

Background

About 70% of neurologists report that PD patients do not get their medication properly when hospitalized, and 33% are prescribed contraindicated drugs.

Objectives

To execute medication reconciliation (MedRec) focused on antiparkinsonian drugs to identify, characterize and, eventually, prevent medication errors, thus promoting therapeutic quality and safety in daily practice.

Methods

An interventional, single-center, 1 year, prospective study. All the patients who were hospitalized and had, at least, one active prescription containing an antiparkinsonian drug at hospital admission were included. MedRec was performed by following a three-phased check: inpatient electronic prescription validation after assessing the outpatient medication schedule, review of the latest clinical report emitted by the Neurology Department/General Practitioner, and pharmacist-driven interview of the patient and/or caregiver to confirm the information regarding medication gathered.

Results

A total of 171 admission episodes from 132 patients were registered (February 1, 2021, and January 31, 2022). Of 224 prescription lines involving antiparkinsonian drugs, 179 contained, at least, one medication error (59.8%). Commission errors (91.62%) were more frequent than omitted drugs (8.38%). The most common medication errors were related to timing (41.90%), frequency (21.23%), and dosing (19.55%). The implementation of this program prevented the erroneous administration of 2716 antiparkinsonian doses, 60% of the total number of doses prescribed. Interestingly, a significant relationship between the number of medication errors and having levodopa prescribed was evidenced (P < 0.05). A contraindicated drug was prescribed in almost one-third of the episodes (29.82%).

Conclusions

Clinical pharmacists' implementation of an antiparkinsonians reconciliation program sharply reduced medication errors and prescription of contraindicated drugs.

Pseudorandomized Testing of a Discharge Medication Alert to Reduce Free-Text Prescribing

BACKGROUND

Pseudorandomized testing can be applied to perform rigorous yet practical evaluations of clinical decision support tools. We apply this methodology to an interruptive alert aimed at reducing free-text prescriptions. Using free-text instead of structured computerized provider order entry elements can cause medication errors and inequity in care by bypassing medication-based clinical decision support tools and hindering automated translation of prescription instructions.

OBJECTIVE

The objective of this study is to evaluate the effectiveness of an interruptive alert at reducing free-text prescriptions via pseudorandomized testing using native electronic health records (EHR) functionality.

METHODS

Two versions of an EHR alert triggered when a provider attempted to sign a discharge free-text prescription. The visible version displayed an interruptive alert to the user, and a silent version triggered in the background, serving as a control. Providers were assigned to the visible and silent arms based on even/odd EHR provider IDs. The proportion of encounters with a free-text prescription was calculated across the groups. Alert trigger rates were compared in process control charts. Free-text prescriptions were analyzed to identify prescribing patterns.

RESULTS

Over the 28-week study period, 143 providers triggered 695 alerts (345 visible and 350 silent). The proportions of encounters with free-text prescriptions were 83% (266/320) and 90% (273/303) in the intervention and control groups, respectively (p = 0.01). For the active alert, median time to action was 31 seconds. Alert trigger rates between groups were similar over time. Ibuprofen, oxycodone, steroid tapers, and oncology-related prescriptions accounted for most free-text prescriptions. A majority of these prescriptions originated from user preference lists.

CONCLUSION

An interruptive alert was associated with a modest reduction in free-text prescriptions. Furthermore, the majority of these prescriptions could have been reproduced using structured order entry fields. Targeting user preference lists shows promise for future intervention.

An electronic pillbox intervention designed to improve medication safety during care transitions: challenges and lessons learned regarding implementation and evaluation

Background

Adverse drug events are common during transitions of care. As part of the Smart Pillbox study, a cluster-randomized controlled trial of an electronic pillbox designed to reduce medication discrepancies and improve medication adherence after hospital discharge, we explored barriers to successful implementation and evaluation of this intervention.

Methods

Eligible patients were those admitted to a medicine service of a large teaching hospital with a plan to be discharged home on five or more chronic medications. The intervention consisted of an electronic pillbox with pre-filled weekly blister pack medication trays given to patients prior to discharge. Pillbox features included alarms to take medications, detection of pill removal from each well, alerts to patients or caregivers by phone, email, or text if medications were not taken, and adherence reports accessible by providers. Greater than 20% missed doses for three days in a row triggered outreach from a pharmacist. To identify barriers to implementation and evaluation of the intervention, we reviewed patient exit surveys, including quantitative data on satisfaction and free-text responses regarding their experiences; technical issue logs; and team meeting minutes. Themes were derived by consensus among the study authors and organized using the Consolidated Framework for Implementation Research.

Results

Barriers to implementation included intervention characteristics such as perceived portability issues with the pillbox and time required by pharmacists to enter medication information into the software; external policies such as lack of insurance coverage for early refills and regulatory prohibitions on repackaging medications; implementation climate issues such as the incompatibility between the rushed nature of hospital discharge with the time required to deploy the intervention; and patient issues such as denial of previous problems with medication adherence. We founds several obstacles to conducting the study, including patients declining study enrollment and limited attempts by the hospital to streamline logistics by building the intervention into usual care. Several solutions to address many of these challenges were implemented or planned. Despite these challenges, many patients with the pillbox were pleased with the service and believed the intervention worked well for them.

Conclusions

In this evaluation, several barriers to implementing and conducting a study of the effectiveness of the intervention were identified. Our findings provide lessons learned for others wishing to implement and evaluate HIT-related interventions designed to improve medication safety during care transitions.

Trial registration

Clinicaltrials.gov NCT03475030

Interprofessional survey on medication reconciliation activities in the US Department of Veterans' Affairs: development and validation of an Implementation Readiness Questionnaire

BACKGROUND

Medication reconciliation (MR) can detect medication history discrepancies at interfaces-in-care and help avoid downstream adverse drug events. However, organisations have struggled to implement high-quality MR programmes. The literature has identified systems barriers, including technology capabilities and data interoperability. However, organisational culture as a root cause has been underexplored.

OBJECTIVES

Our objectives were to develop an implementation readiness questionnaire and measure staff attitudes towards MR across a healthcare enterprise.

METHODS

We developed and distributed a questionnaire to 170 Veterans' Health Affairs (VHA) sites using Research Electronic Data Capture (REDCap) software. The questionnaire contained 21 Likert-scale items that measured three constructs, such as: (1) the extent that clinicians valued MR; (2) perceptions of workflow compatibility and (3) perceptions concerning organisational climate of implementation.

RESULTS

8704 clinicians and staff responded to our questionnaire (142 of 170 VHA facilities). Most staff believed reconciling medications can improve medication safety (approximately 90% agreed it was 'important'). However, most (approximately 90%) also expressed concerns about changes to their workflow. One-third of respondents prioritised other duties over MR and reported barriers associated with implementation climate. Only 47% of respondents agreed they had enough resources to address discrepancies when identified.

INTERPRETATION

Our findings indicate that an MR readiness assessment can forecast challenges and inform development of a context-sensitive implementation bundle. Clinicians surveyed struggled with resources, technology challenges and implementation climate. A strong campaign should include clear leadership messaging, credible champions and resources to overcome technical challenges.

CONCLUSIONS

This manuscript provides a method to conduct a readiness assessment and highlights the importance of organisational culture in an MR campaign. The data can help assess site or network readiness for an MR change management programme.

Evaluation of a web-based medication reconciliation application within a primary care setting: Results from a cluster randomized controlled trial

Background

Despite routine review of medication lists during patient encounters, patients’ medication lists are often incomplete and not reflective of actual medication use. Contributing to this situation is the challenge of reconciling medication information from existing health records, along with external locations (eg, pharmacies, other provider/hospital records, and care facilities) and patient-reported use. Advances in the interoperability and digital collection of information provides a foundation for integration of these once disparate information sources.

Objective

We aim to evaluate the effectiveness of and satisfaction with an electronic health record (EHR)-integrated web-based medication reconciliation application, MedTrue (MT).

Methods

We conducted a cluster-randomized controlled trial of MT in 6 primary care clinics within an integrated health care delivery system. Our primary outcome was medication list accuracy, as determined by a pharmacist-collected best-possible medication history (BPMH). Patient and staff perspectives were evaluated through surveys and semistructured interviews.

Results

Overall, 224 patients were recruited and underwent a BPMH with the pharmacist (n=118 [52.7%] usual care [UC], n=106 [47.3%] MT). For our primary outcome of medication list accuracy, 8 (7.5%) patients in the MT arm and 9 (7.6%) in the UC arm had 0 discrepancies (odds ratio=1.01, 95% CI 0.38-2.72, P=.98). The most common discrepancy identified was patients reporting no longer taking a medication (UC mean 2.48 vs MT mean 2.58, P=.21). Patients found MT easy to use and on average would highly recommend MT (average net promoter score=8/10). Staff found MT beneficial but difficult to implement.

Conclusions

The use of a web-based application integrated into the EHR which combines EHR, patient-reported data, and pharmacy-dispensed data did not improve medication list accuracy among a population of primary care patients compared to UC but was well received by patients. Future studies should address the limitations of the current application and assess whether improved implementation strategies would impact the effectiveness of the application.

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.

Effect of electronic medication reconciliation at the time of hospital discharge on inappropriate medication use in the community: an interrupted time-series analysis

BACKGROUND

It is unclear if enhanced electronic medication reconciliation systems can reduce inappropriate medication use and improve patient care. We evaluated trends in potentially inappropriate medication use after hospital discharge before and after adoption of an electronic medication reconciliation system.

METHODS

We conducted an interrupted time-series analysis in 3 tertiary care hospitals in London, Ontario, using linked health care data (2011-2019). We included patients aged 66 years and older who were discharged from hospital. Starting between Apr. 13 and May 21, 2014, physicians were required to complete an electronic medication reconciliation module for each discharged patient. As a process outcome, we evaluated the proportion of patients who continued to receive a benzodiazepine, antipsychotic or gastric acid suppressant as an outpatient when these medications were first started during the hospital stay. The clinical outcome was a return to hospital within 90 days of discharge with a fall or fracture among patients who received a new benzodiazepine or antipsychotic during their hospital stay. We used segmented linear regression for the analysis.

RESULTS

We identified 15 932 patients with a total of 18 405 hospital discharge episodes. Before the implementation of the electronic medication reconciliation system, 16.3% of patients received a prescription for a benzodiazepine, antipsychotic or gastric acid suppressant after their hospital stay. After implementation, there was a significant and immediate 7.0% absolute decline in this proportion (95% confidence interval [CI] 4.5% to 9.5%). Before implementation, 4.1% of discharged patients who newly received a benzodiazepine or antipsychotic returned to hospital with a fracture or fall within 90 days. After implementation, there was a significant and immediate 2.3% absolute decline in this outcome (95% CI 0.3% to 4.3%).

INTERPRETATION

Implementation of an electronic medication reconciliation system in 3 tertiary care hospitals reduced potentially inappropriate medication use and associated adverse events when patients transitioned back to the community. Enhanced electronic medication reconciliation systems may allow other hospitals to improve patient safety.

Quantifying Discharge Medication Reconciliation Errors at 2 Pediatric Hospitals

Introduction:

Medication reconciliation errors (MREs) are common and can lead to significant patient harm. Quality improvement efforts to identify and reduce these errors typically rely on resource-intensive chart reviews or adverse event reporting. Quantifying these errors hospital-wide is complicated and rarely done. The purpose of this study is to define a set of 6 MREs that can be easily identified across an entire healthcare organization and report their prevalence at 2 pediatric hospitals.

Methods:

An algorithmic analysis of discharge medication lists and confirmation by clinician reviewers was used to find the prevalence of the 6 discharge MREs at 2 pediatric hospitals. These errors represent deviations from the standards for medication instruction completeness, clarity, and safety. The 6 error types are Duplication, Missing Route, Missing Dose, Missing Frequency, Unlisted Medication, and See Instructions errors.

Results:

This study analyzed 67,339 discharge medications and detected MREs commonly at both hospitals. For Institution A, a total of 4,234 errors were identified, with 29.9% of discharges containing at least one error and an average of 0.7 errors per discharge. For Institution B, a total of 5,942 errors were identified, with 42.2% of discharges containing at least 1 error and an average of 1.6 errors per discharge. The most common error types were Duplication and See Instructions errors.

Conclusion:

The presented method shows these MREs to be a common finding in pediatric care. This work offers a tool to strengthen hospital-wide quality improvement efforts to reduce pediatric medication errors.

Advanced Medication Reconciliation: A Systematic Review of the Impact on Medication Errors and Adverse Drug Events Associated with Transitions of Care

OBJECTIVE

The goal of this study was to conduct a systematic review on the impact of in-hospital electronic/enhanced medication reconciliation compared to basic medication reconciliation on medication errors, discrepancies, and adverse drug events (ADEs).

METHODS

The study team searched for peer-reviewed English-language articles in EMBASE, OVID, and Scopus databases up to October 2019. Included were randomized controlled trials (RCTs), pre-post, or interrupted time series designs with medication errors, discrepancies, or ADEs as an outcome, and medication reconciliation applied at hospital discharge. Basic medication reconciliation was defined as using a paper-based format, electronic medication reconciliation as using an electronic format, and enhanced medication reconciliation as incorporating additional interventions to reduce medication errors.

RESULTS

Ten studies (three RCTs, one retrospective cohort study, two interrupted time series studies, three pre-post studies, and one longitudinal study) were identified, with six and four studies comparing basic medication reconciliation to electronic and enhanced medication reconciliation, respectively. The overall risk of bias of the included studies was low (three), unclear (two), moderate (three), and serious/high (two). In general, studies demonstrated that electronic medication reconciliation reduced the odds of a medication discrepancy or ADE and may reduce the mean number of medication discrepancies. Enhanced medication reconciliation was more equivocal, with some studies showing improvement; however, risk of bias was generally significant.

CONCLUSION

Electronic medication reconciliation tends to reduce the risk of ADE; however, these conclusions were limited due to a lack of consistency in study settings, interventions, and outcome definitions. Future studies with more rigorous designs and standardized outcome definitions would provide clarity on this topic.

Medication review and reconciliation in older adults

Older people are frequently exposed to polypharmacy, inappropriate prescribing, and adverse drug events. Two clinical processes can help geriatricians to optimize and increase the safety of drug prescriptions for older adults: medication reconciliation and medication review. Medication reconciliation provides the best possible medication history and identifies and resolves discrepancies in drug prescriptions. During the medication review, the best possible medication history is crosschecked against other data, including morbidities, patient's preferences, or geriatric syndromes, to produce a personalized medication strategy. Alignment of treatment recommendations with patient preferences and goals through shared decision-making is particularly important in medication review. Medication reconciliation and medication review have proven to be effective, but their broad implementation remains difficult. Indeed, these procedures are time-consuming and require specific skills, coordination between different healthcare professionals, organizations and dedicated means. The involvement of geriatricians therefore remains essential for the successful implementation of medication reconciliation and medication review in geriatric settings and among frail older people.

Easy Medication Reconciliation at Hospital Admission: The EzMedRec Decision Support System

Medication reconciliation (MR) aims at preventing medication errors at care transitions. It is a complex, time-consuming, cognitively demanding pharmacological task. We have developed a decision support system, EzMedRec, to assist retroactive MR at hospital admission. EzMedRec compares the best possible medication history (BPMH), i.e., all medications taken by the patient before hospitalization, to the list of admission medication orders (AMO). The process includes (i) the decomposition of BPMH and AMO drugs into their active ingredients (AIs), (ii) the detection of medication discontinuations and additions, and (iii) the identification of modified medication orders. The ATC classification is used to semantically enrich MR by comparing discontinued AIs and added AIs and suggesting a potential intentional drug substitution serving the same therapeutic objective. EzMedRec has been evaluated on a sample of 52 actual MRs involving 822 medication order lines, 406 in BPMHs, and 416 in AMOs with a global accuracy of 98,3%.

Improving Transfer Medication Reconciliation in an Emirati Tertiary Hospital Utilizing the Irish Health Service Executive Model

Transfer is a vulnerable setting that increases the risk of medication errors. Medication reconciliation (MedRec) ensures accurate medication transfer at interfaces of care. It is addressed as a key performance indicator (KPI) in a tertiary hospital. The issue was failure to meet the KPI of more than 75%; the objective was to improve compliance with transfer MedRec. A quality improvement project was conducted utilizing physician active education, leadership support, and the Irish Health Service Executive (HSE) change model. Compliance with the KPI did not improve with monthly monitoring and physician education. Following leadership support, compliance increased from 56% to 72% but was not sustained. Adoption of the change model yielded a sustainable improvement from 65% to 81% within 1 year of the intervention and a reduction in medication errors. Improvement in the MedRec process requires a culture of accountability to change. HSE expedited stakeholders' engagement and implementation of the planned interventions.

Effects of interorganisational information technology networks on patient safety: a realist synthesis

OBJECTIVE

Health services in many countries are investing in interorganisational networks, linking patients' records held in different organisations across a city or region. The aim of the systematic review was to establish how, why and in what circumstances these networks improve patient safety, fail to do so, or increase safety risks, for people living at home.

DESIGN

Realist synthesis, drawing on both quantitative and qualitative evidence, and including consultation with stakeholders in nominal groups and semistructured interviews.

ELIGIBILITY CRITERIA

The coordination of services for older people living at home, and medicine reconciliation for older patients returning home from hospital.

INFORMATION SOURCES

17 sources including Medline, Embase, CINAHL, Cochrane Library, Web of Science, ACM Digital Library, and Applied Social Sciences Index and Abstracts.

OUTCOMES

Changes in patients' clinical risks.

RESULTS

We did not find any detailed accounts of the sequences of events that policymakers and others believe will lead from the deployment of interoperable networks to improved patient safety. We were, though, able to identify a substantial number of theory fragments, and these were used to develop programme theories.There is good evidence that there are problems with the coordination of services in general, and the reconciliation of medication lists in particular, and it indicates that most problems are social and organisational in nature. There is also good evidence that doctors and other professionals find interoperable networks difficult to use. There was limited high-quality evidence about safety-related outcomes associated with the deployment of interoperable networks.

CONCLUSIONS

Empirical evidence does not currently justify claims about the beneficial effects of interoperable networks on patient safety. There appears to be a mismatch between technology-driven assumptions about the effects of networks and the sociotechnical nature of coordination problems.

PROSPERO REGISTRATION NUMBER

CRD42017073004.

The effects of interoperable information technology networks on patient safety: a realist synthesis

Background

Interoperable networks connect information technology systems of different organisations, allowing professionals in one organisation to access patient data held in another one. Health policy-makers in many countries believe that they will improve the co-ordination of services and, hence, the quality of services and patient safety. To the best of our knowledge, there have not been any previous systematic reviews of the effects of these networks on patient safety.

Objectives

The aim of the study was to establish how, why and in what circumstances interoperable information technology networks improved patient safety, failed to do so or increased safety risks. The objectives of the study were to (1) identify programme theories and prioritise theories to review; (2) search systematically for evidence to test the theories; (3) undertake quality appraisal, and use included texts to support, refine or reject programme theories; (4) synthesise the findings; and (5) disseminate the findings to a range of audiences.

Design

Realist synthesis, including consultation with stakeholders in nominal groups and semistructured interviews.

Settings and participants

Following a stakeholder prioritisation process, several domains were reviewed: older people living at home requiring co-ordinated care, at-risk children living at home and medicines reconciliation services for any patients living at home. The effects of networks on services in health economies were also investigated.

Intervention

An interoperable network that linked at least two organisations, including a maximum of one hospital, in a city or region.

Outcomes

Increase, reduction or no change in patients’ risks, such as a change in the risk of taking an inappropriate medication.

Results

We did not find any detailed accounts of the ways in which interoperable networks are intended to work and improve patient safety. Theory fragments were identified and used to develop programme and mid-range theories. There is good evidence that there are problems with the co-ordination of services in each of the domains studied. The implicit hypothesis about interoperable networks is that they help to solve co-ordination problems, but evidence across the domains showed that professionals found interoperable networks difficult to use. There is insufficient evidence about the effectiveness of interoperable networks to allow us to establish how and why they affect patient safety.

Limitations

The lack of evidence about patient-specific measures of effectiveness meant that we were not able to determine ‘what works’, nor any variations in what works, when interoperable networks are deployed and used by health and social care professionals.

Conclusions

There is a dearth of evidence about the effects of interoperable networks on patient safety. It is not clear if the networks are associated with safer treatment and care, have no effects or increase clinical risks.

Future work

Possible future research includes primary studies of the effectiveness of interoperable networks, of economies of scope and scale and, more generally, on the value of information infrastructures.

Study registration

This study is registered as PROSPERO CRD42017073004.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 40. See the NIHR Journals Library website for further project information.

Electronic Documentation in Pediatrics: The Rationale and Functionality Requirements

Clinical documentation has dramatically changed since the implementation and use of electronic health records and electronic provider documentation. The purpose of this report is to review these changes and promote the development of standards and best practices for electronic documentation for pediatric patients. In this report, we evaluate the unique aspects of clinical documentation for pediatric care, including specialized information needs and stakeholders specific to the care of children. Additionally, we explore new models of documentation, such as shared documentation, in which patients may be both authors and consumers, and among care teams while still maintaining the ability to clearly define care and services provided to patients in a given day or encounter. Finally, we describe alternative documentation techniques and newer technologies that could improve provider efficiency and the reuse of clinical data.

A web application to involve patients in the medication reconciliation process: a user-centered usability and usefulness study

Objective

Medication reconciliation (MedRec) can improve patient safety by resolving medication discrepancies. Because information technology (IT) and patient engagement are promising approaches to optimizing MedRec, the SEAMPAT project aims to develop a MedRec IT platform based on two applications: the "patient app" and the "MedRec app." This study evaluates three dimensions of the usability (efficiency, satisfaction, and effectiveness) and usefulness of the patient app.

Methods

We performed a four-month user-centered observational study. Quantitative and qualitative data were collected. Participants completed the system usability scale (SUS) questionnaire and a second questionnaire on usefulness. Effectiveness was assessed by measuring the completeness of the medication list generated by the patient application and its correctness (ie medication discrepancies between the patient list and the best possible medication history). Qualitative data were collected from semi-structured interviews, observations and comments, and questions raised by patients.

Results

Forty-two patients completed the study. Sixty-nine percent of patients considered the patient app to be acceptable (SUS Score ≥ 70) and usefulness was high. The medication list was complete for a quarter of the patients (7/28) and there was a discrepancy for 21.7% of medications (21/97). The qualitative data enabled the identification of several barriers (related to functional and non-functional aspects) to the optimization of usability and usefulness.

Conclusions

Our findings highlight the importance and value of user-centered usability testing of a patient application implemented in "real-world" conditions. To achieve adoption and sustained use by patients, the app should meet patients' needs while also efficiently improving the quality of MedRec.

Higher accuracy of complex medication reconciliation through improved design of electronic tools

Objective

Investigate the accuracy of 2 different medication reconciliation tools integrated into electronic health record systems (EHRs) using a cognitively demanding scenario and complex medication history.

Materials and Methods

Seventeen physicians reconciled medication lists for a polypharmacy patient using 2 EHRs in a simulation study. The lists contained 3 types of discrepancy and were transmitted between the systems via a Continuity of Care Document. Participants updated each EHR and their interactions were recorded and analyzed for the number and type of errors.

Results

Participants made 748 drug comparisons that resulted in 53 errors (93% accuracy): 12 using EHR2 (3% rate, 0-3 range) and 41 using EHR1 (11% rate, 0-9 range; P < .0001). Twelve clinicians made completely accurate reconciliations with EHR2 (71%) and 6 with EHR1 (35%). Most errors (28, 53%) occurred in medication entries containing discrepancies: 4 in EHR2 and 24 in EHR1 (P = .008). The order in which participants used the EHRs to complete the task did not affect the results.

Discussion

Significantly fewer errors were made with EHR2, which presented lists in a side-by-side view, automatically grouped medications by therapeutic class and more effectively identified duplicates. Participants favored this design and indicated that they routinely used several workarounds in EHR1.

Conclusion

Accurate assessment of the safety and effectiveness of electronic reconciliation tools requires rigorous testing and should prioritize complex rather than simpler tasks that are currently used for EHR certification and product demonstration. Higher accuracy of reconciliation is likely when tools are designed to better support cognitively demanding tasks.

An On-Treatment Analysis of the MARQUIS Study: Interventions to Improve Inpatient Medication Reconciliation

It is unclear which medication reconciliation interventions are most effective at reducing inpatient medication discrepancies. Five United States hospitals' interdisciplinary quality improvement (QI) teams were virtually mentored by QI-trained physicians. Sites implemented one to seven evidence-based interventions in 791 patients during the 25-month implementation period. Three interventions were associated with significant decreases in potentially harmful discrepancy rates: (1) defining clinical roles and responsibilities, (2) training, and (3) hiring staff to perform discharge medication reconciliation. Two interventions were associated with significant increases in potentially harmful discrepancy rates: training staff to take medication histories and implementing a new electronic health record (EHR). Hospitals should focus first on hiring and training pharmacy staff to assist with medication reconciliation at discharge and delineating roles and responsibilities of clinical staff. We caution hospitals implementing a large vendor EHR, as medication discrepancies may increase. Finally, the effect of medication history training on discrepancies needs further study.

Effect of an Electronic Medication Reconciliation Intervention on Adverse Drug Events: A Cluster Randomized Trial

IMPORTANCE

Adverse drug events (ADEs) account for up to 16% of emergency department (ED) visits and 7% of hospital admissions. Medication reconciliation is required for hospital accreditation because it can reduce medication discrepancies, but there is no evidence that reducing discrepancies reduces ADEs or other adverse outcomes.

OBJECTIVE

To evaluate whether electronic medication reconciliation reduces ADEs, medication discrepancies, and other adverse outcomes compared with usual care.

DESIGN, SETTING, AND PARTICIPANTS

This cluster randomized trial involved 3491 patients who were discharged from 2 medical units and 2 surgical units at the McGill University Health Centre, Montreal, Quebec, Canada, between October 2014 and November 2016. Data analysis took place from July 2017 to July 2019.

INTERVENTION

The RightRx intervention electronically retrieved community drugs from the provincial insurer and aligned them with in-hospital drugs to facilitate reconciliation and communication at care transitions.

MAIN OUTCOMES AND MEASURES

The primary outcome was ADEs in 30 days after discharge. Secondary outcomes included medication discrepancies, ED visits, hospital readmissions, and a composite outcome of ED visits, readmissions, and death up to 90 days after discharge.

RESULTS

Of 4656 eligible patients, 3567 (76.6%) consented to participate (2060 [57.8%] men; mean [SD] age, 69.8 [14.9] years). Overall, 76 patients died during the hospital stay, so 3491 patients were included in the analysis. There was no significant difference in the risk of ADEs between intervention and control groups (76 [4.6%] vs 73 [4.0%]; OR, 0.97; 95% CI, 0.33-1.48), ED visits (433 [26.2%] vs 488 [26.6%]; OR, 0.83; 95% CI, 0.36-1.42), hospital readmission (170 [10.3%] vs 261 [14.2%]; OR, 0.22; 95% CI, 0.06-1.14), or the composite outcome (447 [27.0%] vs 506 [27.6%]; OR, 0.75; 95% CI, 0.34-1.27) at 30 days. Medication discrepancies were significantly reduced in the intervention group compared with the control group (437 [26.4%] vs 1029 [56.0%]; OR, 0.24; 95% CI, 0.12-0.57). Changes made to community medications (OR, 1.05; 95% CI, 1.01-1.10) and new medications (OR, 1.09; 95% CI, 1.01-1.18) were significant risk factors for ADEs.

CONCLUSIONS AND RELEVANCE

Electronic medication reconciliation reduced medication discrepancies but did not reduce ADEs or other adverse outcomes. Hospital accreditation should focus on interventions that reduce the risk of adverse events for patients with multiple changes to community medications.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01179867.

A User-Centered design and usability testing of a web-based medication reconciliation application integrated in an eHealth network

BACKGROUND

Medication discrepancies, which are a threat to patient safety, can be reduced by medication reconciliation (MedRec). MedRec is a complex process that can be supported by the use of information technology and patient engagement. Therefore, the SEAMPAT project aims to develop a MedRec IT platform based on two applications. The application for the professionals is called: the "MedRec app".

OBJECTIVE

In the present study, we aimed to describe the development and usability testing of the MedRec app, reporting results of a three iterations user-centered usability evaluation.

METHODS

We used a three phase iterative user-centered study spread over 16 months. At each phase, the usability evaluation included several methods (observations, questionnaires, and follow-up discussions with participants) to collect quantitative and qualitative data in order to improve the current prototype and evolve to the next prototype.

RESULTS

In total, 48 healthcare professionals (25 general practitioners and 23 hospital clinicians) participated to the MedRec app evaluation. There were 14, 32 and 5 participants for phases 1, 2 and 3 respectively. At each phase, many design modifications were done to strengthen usability. Concerning usability, participants considered the prototypes as an acceptable interface with a median System Usability Score of 73 at phase 2 and 75 at phase 3. Participants emphasized the need for improvements concerning workflow integration, usefulness and interoperability.

CONCLUSION

The MedRec app was perceived as being useful, usable and satisfying. However, further improvements are required in several usability aspects. Our study demonstrates the importance of conducting usability assessments before investing time and resources in a large study evaluating the effect of an eMedRec approach on clinical outcomes. Our findings may also increase the chances of acceptability and sustained use over time by clinicians.

A Systematic Review of Open Source Clinical Software on GitHub for Improving Software Reuse in Smart Healthcare

The plethora of open source clinical software offers great reuse opportunities for developers to build clinical tools at lower cost and at a faster pace. However, the lack of research on open source clinical software poses a challenge for software reuse in clinical software development. This paper aims to help clinical developers better understand open source clinical software by conducting a thorough investigation of open source clinical software hosted on GitHub. We first developed a data pipeline that automatically collected and preprocessed GitHub data. Then, a deep analysis with several methods, such as statistical analysis, hypothesis testing, and topic modeling, was conducted to reveal the overall status and various characteristics of open source clinical software. There were 14,971 clinical-related GitHub repositories created during the last 10 years, with an average annual growth rate of 55%. Among them, 12,919 are open source clinical software. Our analysis unveiled a number of interesting findings: Popular open source clinical software in terms of the number of stars, most productive countries that contribute to the community, important factors that make an open source clinical software popular, and 10 main groups of open source clinical software. The results can assist both researchers and practitioners, especially newcomers, in understanding open source clinical software.

Effects of a multifaceted medication reconciliation quality improvement intervention on patient safety: final results of the MARQUIS study

BACKGROUND

Unintentional discrepancies across care settings are a common form of medication error and can contribute to patient harm. Medication reconciliation can reduce discrepancies; however, effective implementation in real-world settings is challenging.

METHODS

We conducted a pragmatic quality improvement (QI) study at five US hospitals, two of which included concurrent controls. The intervention consisted of local implementation of medication reconciliation best practices, utilising an evidence-based toolkit with 11 intervention components. Trained QI mentors conducted monthly site phone calls and two site visits during the intervention, which lasted from December 2011 through June 2014. The primary outcome was number of potentially harmful unintentional medication discrepancies per patient; secondary outcome was total discrepancies regardless of potential for harm. Time series analysis used multivariable Poisson regression.

RESULTS

Across five sites, 1648 patients were sampled: 613 during baseline and 1035 during the implementation period. Overall, potentially harmful discrepancies did not decrease over time beyond baseline temporal trends, adjusted incidence rate ratio (IRR) 0.97 per month (95% CI 0.86 to 1.08), p=0.53. The intervention was associated with a reduction in total medication discrepancies, IRR 0.92 per month (95% CI 0.87 to 0.97), p=0.002. Of the four sites that implemented interventions, three had reductions in potentially harmful discrepancies. The fourth site, which implemented interventions and installed a new electronic health record (EHR), saw an increase in discrepancies, as did the fifth site, which did not implement any interventions but also installed a new EHR.

CONCLUSIONS

Mentored implementation of a multifaceted medication reconciliation QI initiative was associated with a reduction in total, but not potentially harmful, medication discrepancies. The effect of EHR implementation on medication discrepancies warrants further study.

TRIAL REGISTRATION NUMBER

NCT01337063.

Characterization of drug-drug interactions in patients whose substance intake was objectively identified by detection in urine

BACKGROUND

Identification of drug-drug interactions (DDIs) typically relies on patient medication lists which are prone to inaccuracies. This study describes use of a mass spectrometry test to detect recently ingested substances in urine with subsequent identification of DDIs.

RESEARCH DESIGN AND METHODS

This was a retrospective analysis of the prevalence of DDIs identified in patients with chronic pain, addiction and/or behavioral health conditions in the U.S. Relationships between patient demographics, polypharmacy and the occurrence of DDIs were also described.

RESULTS

Of 15,004 patients, 2964 (20%) had a DDI identified. There was a positive association between the number of substances detected in urine and the number of interactions identified (r = 0.5033, p-value = 0.0001). Of patients with polypharmacy, 15.6% had contraindicated or severe interactions identified compared to only 3.2% of those without polypharmacy. For polypharmacy patients, the youngest population studied had a much higher likelihood of having one or more DDIs identified compared to the other age groups (p-value = 0.0002).

CONCLUSIONS

By utilizing a mass spectrometry test to objectively detect recently ingested substances followed by identification of DDIs, healthcare providers may be able to better characterize the true incidence of DDIs. Study findings may not be generalizable to healthcare populations outside of pain management, addiction treatment, and behavioral health.

Evaluation of Multimedia Medication Reconciliation Software: A Randomized Controlled, Single-Blind Trial to Measure Diagnostic Accuracy for Discrepancy Detection

BACKGROUND

The Veterans Affairs Portland Healthcare System developed a medication history collection software that displays prescription names and medication images.

OBJECTIVE

This article measures the frequency of medication discrepancy reporting using the medication history collection software and compares with the frequency of reporting using a paper-based process. This article also determines the accuracy of each method by comparing both strategies to a best possible medication history.

STUDY DESIGN

Randomized, controlled, single-blind trial.

SETTING

Three community-based primary care clinics associated with the Veterans Affairs Portland Healthcare System: a 300-bed teaching facility and ambulatory care network serving Veteran soldiers in the Pacific Northwest United States.

PARTICIPANTS

Of 212 patients with primary care appointments, 209 patients fulfilled the study requirements.

INTERVENTION

Patients randomized to a software-directed medication history or a paper-based medication history. Randomization and allocation to treatment groups were performed using a computer-based random number generator. Assignments were placed in a sealed envelope and opened after participant consent. The research coordinator did not know or have access to the treatment assignment until the time of presentation.

MAIN OUTCOME MEASURES

The primary analysis compared the discrepancy detection rates between groups with respect to the health record and a best possible medication history.

RESULTS

Of 3,500 medications reviewed, we detected 1,435 discrepancies. Forty-six percent of those discrepancies were potentially high risk for causing an adverse drug event. There was no difference in detection rates between treatment arms. Software sensitivity was 83% and specificity was 91%; paper sensitivity was 81% and specificity was 94%. No participants were lost to follow-up.

CONCLUSION

The medication history collection software is an efficient and scalable method for gathering a medication history and detecting high-risk discrepancies. Although it included medication images, the technology did not improve accuracy over a paper list when compared with a best possible medication history.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02135731.

Improving patient safety and efficiency of medication reconciliation through the development and adoption of a computer-assisted tool with automated electronic integration of population-based community drug data: the RightRx project

Background and Objective

Many countries require hospitals to implement medication reconciliation for accreditation, but the process is resource-intensive, thus adherence is poor. We report on the impact of prepopulating and aligning community and hospital drug lists with data from population-based and hospital-based drug information systems to reduce workload and enhance adoption and use of an e-medication reconciliation application, RightRx.

Methods

The prototype e-medical reconciliation web-based software was developed for a cluster-randomized trial at the McGill University Health Centre. User-centered design and agile development processes were used to develop features intended to enhance adoption, safety, and efficiency. RightRx was implemented in medical and surgical wards, with support and training provided by unit champions and field staff. The time spent per professional using RightRx was measured, as well as the medication reconciliation completion rates in the intervention and control units during the first 20 months of the trial.

Results

Users identified required modifications to the application, including the need for dose-based prescribing, the role of the discharge physician in prescribing community-based medication, and access to the rationale for medication decisions made during hospitalization. In the intervention units, both physicians and pharmacists were involved in discharge reconciliation, for 96.1% and 71.9% of patients, respectively. Medication reconciliation was completed for 80.7% (surgery) to 96.0% (medicine) of patients in the intervention units, and 0.7% (surgery) to 82.7% of patients in the control units. The odds of completing medication reconciliation were 9 times greater in the intervention compared to control units (odds ratio: 9.0, 95% confidence interval, 7.4-10.9, P < .0001) after adjusting for differences in patient characteristics.

Conclusion

High rates of medication reconciliation completion were achieved with automated prepopulation and alignment of community and hospital medication lists.

Implementation of a Medication Reconciliation Assistive Technology: A Qualitative Analysis

Objective: To aid the implementation of a medication reconciliation process within a hybrid primary-specialty care setting by using qualitative techniques to describe the climate of implementation and provide guidance for future projects. Methods: Guided by McMullen et al's Rapid Assessment Process¹, we performed semi-structured interviews prior to and iteratively throughout the implementation. Interviews were coded and analyzed using grounded theory² and cross-examined for validity. Results: We identified five barriers and five facilitators that impacted the implementation. Facilitators identified were process alignment with user values, and motivation and clinical champions fostered by the implementation team rather than the administration. Barriers included a perceived limited capacity for change, diverging priorities, and inconsistencies in process standards and role definitions. Discussion: A more complete, qualitative understanding of existing barriers and facilitators helps to guide critical decisions on the design and implementation of a successful medication reconciliation process.

Developing a Shared Patient-Centered, Web-Based Medication Platform for Type 2 Diabetes Patients and Their Health Care Providers: Qualitative Study on User Requirements

BACKGROUND

Information technology tools such as shared patient-centered, Web-based medication platforms hold promise to support safe medication use by strengthening patient participation, enhancing patients' knowledge, helping patients to improve self-management of their medications, and improving communication on medications among patients and health care professionals (HCPs). However, the uptake of such platforms remains a challenge also due to inadequate user involvement in the development process. Employing a user-centered design (UCD) approach is therefore critical to ensure that user' adoption is optimal.

OBJECTIVE

The purpose of this study was to identify what patients with type 2 diabetes mellitus (T2DM) and their HCPs regard necessary requirements in terms of functionalities and usability of a shared patient-centered, Web-based medication platform for patients with T2DM.

METHODS

This qualitative study included focus groups with purposeful samples of patients with T2DM (n=25), general practitioners (n=13), and health care assistants (n=10) recruited from regional health care settings in southwestern Germany. In total, 8 semistructured focus groups were conducted. Sessions were audio- and video-recorded, transcribed verbatim, and subjected to a computer-aided qualitative content analysis.

RESULTS

Appropriate security and access methods, supported data entry, printing, and sending information electronically, and tracking medication history were perceived as the essential functionalities. Although patients wanted automatic interaction checks and safety alerts, HCPs on the contrary were concerned that unspecific alerts confuse patients and lead to nonadherence. Furthermore, HCPs were opposed to patients' ability to withhold or restrict access to information in the platform. To optimize usability, there was consensus among participants to display information in a structured, chronological format, to provide information in lay language, to use visual aids and customize information content, and align the platform to users' workflow.

CONCLUSIONS

By employing a UCD, this study provides insight into the desired functionalities and usability of patients and HCPs regarding a shared patient-centered, Web-based medication platform, thus increasing the likelihood to achieve a functional and useful system. Substantial and ongoing engagement by all intended user groups is necessary to reconcile differences in requirements of patients and HCPs, especially regarding medication safety alerts and access control. Moreover, effective training of patients and HCPs on medication self-management (support) and optimal use of the tool will be a prerequisite to unfold the platform's full potential.

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

Background  While evidence generally supports the use of medication management technology, systems are typically implemented and evaluated piecemeal rather than as part of a comprehensive model for medication management. Systems to support drug therapy optimization, increasingly a key role of pharmacists in our healthcare system, have not yet been reported.

Objective  Our objective is to describe the design, implementation, and use of health information technology to support the hospital and community pharmacists' management of medications for high-risk patients statewide in the “Pharm2Pharm” model of care. Our aims were to make it easier for the pharmacists to access information needed to identify and resolve drug therapy problems using best practices for medication management and communicate with other members of the care team.

Methods  The pharmacist's roles and the medication management processes guided the design of the supporting technology, which was implemented after the Pharm2Pharm model was launched and the pharmacists' technology needs were assessed. Priorities for technology included sending care transition documents from hospital to community pharmacist securely and efficiently, access to medical records, including medications and laboratory results, documentation, and patient tracking. Implementation and use of the technology were documented.

Results  Communications, medication management, and population management solutions were implemented to support the Pharm2Pharm model. The pharmacists delivering services through this model adopted and meaningfully used this technology to support their work.

Conclusion  Implementing technology with value outside of the Pharm2Pharm model was a strategic approach to investment. This work emphasizes the importance of shifting the focus of technology from supporting a specific piece of the medication management process to supporting the goal of optimizing medication regimens. Health information exchange systems can provide important technology needed to integrate pharmacists into care teams as they are deployed to improve patient outcomes.

Measuring to Improve Medication Reconciliation in a Large Subspecialty Outpatient Practice

BACKGROUND

To assess performance in medication reconciliation (med rec)-the process of comparing and reconciling patients' medication lists at clinical transition points-and demonstrate improvement in an outpatient setting, sustainable and valid measures are needed.

METHODS

An interdisciplinary team at National Jewish Health (Denver) attempted to improve med rec in an ambulatory practice serving patients with respiratory and related diseases. Interventions, which were aimed at physicians, nurses (RNs), and medical assistants, involved changes in practice and changes in documentation in the electronic health record (EHR). New measures designed to assess med rec performance, and to validate the measures, were derived from EHR data.

RESULTS

Across 18 months, electronic attestation that med rec was completed at clinic visits increased from 9.8% to 91.3% (p <0.0001). Consistent with this improvement, patients with medication lists missing dose/frequency for at least one prescription-type medication decreased from 18.1% to 15.8% (p <0.0001). Patients with duplicate albuterol inhalers on their list decreased from 4.0% to 2.6% (p <0.0001). Percentages of patients increased for printing of the medication list at the visit (18.7% to 94.0%; p <0.0001) and receipt of the printed medication list at the visit (52.3% to 67.0%; p = 0.0074). Documentation that patient education handouts were offered increased initially then declined to an overall poor performance of 32.4% of clinic visits. Investigation of this result revealed poor buy-in and a highly redundant process.

CONCLUSION

Deriving measures reflecting performance and quality of med rec from EHR data is feasible and sustainable over the time periods necessary to demonstrate change. Concurrent, complementary measures may be used to support the validity of summary measures.