Meaningful use of health information technology and declines in in-hospital adverse drug events

Methods for studying medication safety following electronic health record implementation in acute care: a scoping review

OBJECTIVES

The objective of this scoping review is to map methods used to study medication safety following electronic health record (EHR) implementation. Patterns and methodological gaps can provide insight for future research design.

MATERIALS AND METHODS

We used the Joanna Briggs Institute scoping review methodology and a custom data extraction table to summarize the following data: (1) study demographics (year, country, setting); (2) study design, study period, data sources, and measures; (3) analysis strategy; (4) identified limitations or recommendations; (5) quality appraisal; and (6) if a Safety-I or Safety-II perspective was employed.

RESULTS

We screened 5879 articles. One hundred and fifteen articles met our inclusion criteria and were assessed for eligibility by full-text review. Twenty-seven articles were eligible for extraction.

DISCUSSION AND CONCLUSION

We found little consistency in how medication safety following EHR implementation was studied. Three study designs, 7 study settings, and 10 data sources were used across 27 articles. None of the articles shared the same combination of design, data sources, study periods, and research settings. Outcome measures were neither defined nor measured consistently. It may be difficult for researchers to aggregate and synthesize medication safety findings following EHR implementation research. All studies but one used a Safety-I perspective to study medication safety. We offer a conceptual model to support a more consistent approach to studying medication safety following EHR implementation.

The Value of Electronic Health Records Since the Health Information Technology for Economic and Clinical Health Act: Systematic Review

Background

Electronic health records (EHRs) are the electronic records of patient health information created during ≥1 encounter in any health care setting. The Health Information Technology Act of 2009 has been a major driver of the adoption and implementation of EHRs in the United States. Given that the adoption of EHRs is a complex and expensive investment, a return on this investment is expected.

Objective

This literature review aims to focus on how the value of EHRs as an intervention is defined in relation to the elaboration of value into 2 different value outcome categories, financial and clinical outcomes, and to understand how EHRs contribute to these 2 value outcome categories.

Methods

This literature review was conducted using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). The initial search of key terms, EHRs, values, financial outcomes, and clinical outcomes in 3 different databases yielded 971 articles, of which, after removing 410 (42.2%) duplicates, 561 (57.8%) were incorporated in the title and abstract screening. During the title and abstract screening phase, articles were excluded from further review phases if they met any of the following criteria: not relevant to the outcomes of interest, not relevant to EHRs, nonempirical, and non–peer reviewed. After the application of the exclusion criteria, 80 studies remained for a full-text review. After evaluating the full text of the residual 80 studies, 26 (33%) studies were excluded as they did not address the impact of EHR adoption on the outcomes of interest. Furthermore, 4 additional studies were discovered through manual reference searches and were added to the total, resulting in 58 studies for analysis. A qualitative analysis tool, ATLAS.ti. (version 8.2), was used to categorize and code the final 58 studies.

Results

The findings from the literature review indicated a combination of positive and negative impacts of EHRs on financial and clinical outcomes. Of the 58 studies surveyed for this review of the literature, 5 (9%) reported on the intersection of financial and clinical outcomes. To investigate this intersection further, the category “Value–Intersection of Financial and Clinical Outcomes” was generated. Approximately 80% (4/5) of these studies specified a positive association between EHR adoption and financial and clinical outcomes.

Conclusions

This review of the literature reports on the individual and collective value of EHRs from a financial and clinical outcomes perspective. The collective perspective examined the intersection of financial and clinical outcomes, suggesting a reversal of the current understanding of how IT investments could generate improvements in productivity, and prompted a new question to be asked about whether an increase in productivity could potentially lead to more IT investments.

Governance for Patient Safety: A Framework of Strategy Domains for Risk Management

BACKGROUND

Adverse events in healthcare are primarily due to system failures rather than individuals. Risk reduction strategies should therefore focus on strengthening systems, bringing about improvements in governance, and targeting individual practices or products. The purpose of this study was to conduct a scoping review to develop a global framework of management strategies for sustaining a safety-oriented culture in healthcare organizations, focusing on patient safety and the adoption of good safety-related practices.

METHODS

We conducted a search on safety-related strategies in 2 steps. The first involved a search in the PubMed database to identify effective, broadly framed, cross-sector domains relevant to clinical risk management strategies in healthcare systems. In the second step, we then examined the strategies adopted by running a scoping review for each domain.

RESULTS

Our search identified 8 strategy domains relevant to patient safety: transformational leadership, patient engagement, human resources management quality, innovation technology, skills certification, education in patient safety, teamwork, and effective communication.

CONCLUSIONS

This scoping review explores management strategies key to healthcare systems' efforts to create safety-oriented organizations. Improvement efforts should focus particularly on the domains identified: combined together, they would nurture an overall safety-oriented culture and have an impact on preventable adverse events.

Assessing Consistency of Drug-Drug Interaction-Related Information Across Various Drug Information Resources

Background

Information related to drug-drug interactions (DDIs) varies significantly from one drug information (DI) resource to another. These variations pose challenges for healthcare professionals in making the right decisions regarding using some of the drug combinations in needy patients. The objective of this study was to review eight different DI resources for scope, completeness, and consistency of information related to DDIs.

Methodology

A total of eight DI resources, namely, Micromedex^®, Portable Electronic Physician Information Database^©, UpToDate^®, Medscape.com drug interaction checker, Drugs.com drug interaction checker, Stockley’s Drug Interactions (ninth edition, 2010), Drug Interactions Analysis & Management: Facts and Comparisons 2014 (ninth edition, 2014), and the drug interaction appendix of the British National Formulary-76, were compared. Each DI resource was scored for scope by calculating the percentage of interactions that had an entry in each resource. A completeness score was calculated for each resource describing severity, clinical effects, mechanism, and DDI management. The consistency of the information was assessed using Fleiss Kappa (k) score estimated using ReCal3 0.1 (alpha) web service and Statistical Package for the Social Sciences version 24.

Results

The scope score was the highest (100%) for UpToDate^® and Portable Electronic Physician Information Database^©, whereas the completeness score was the highest (100%) for Drug Interaction Analysis & Management: Facts and comparisons 2014. The inter-source reliability scores among the eight different DI sources were poor (k < 0.20, p < 0.05) for documentation of information related to severity, clinical effects, mechanism, and management of DDIs.

Conclusions

Variations in the information cause uncertainty among healthcare professionals concerning interacting drug pairs in clinical practice. This may also increase the possibility of adverse drug outcomes when interacting drug pairs are used in at-risk patients. We recommend comprehensive preventive and management strategies for DDIs depending on a uniform scale of severity and clinical effects across various DI resources.

Impact of electronic health records on predefined safety outcomes in patients admitted to hospital: a scoping review

OBJECTIVES

Review available evidence for impact of electronic health records (EHRs) on predefined patient safety outcomes in interventional studies to identify gaps in current knowledge and design interventions for future research.

DESIGN

Scoping review to map existing evidence and identify gaps for future research.

DATA SOURCES

PubMed, the Cochrane Library, EMBASE, Trial registers.

STUDY SELECTION

Eligibility criteria: We conducted a scoping review of bibliographic databases and the grey literature of randomised and non-randomised trials describing interventions targeting a list of fourteen predefined areas of safety. The search was limited to manuscripts published between January 2008 and December 2018 of studies in adult inpatient settings and complemented by a targeted search for studies using a sample of EHR vendors. Studies were categorised according to methodology, intervention characteristics and safety outcome.Results from identified studies were grouped around common themes of safety measures.

RESULTS

The search yielded 583 articles of which 24 articles were included. The identified studies were largely from US academic medical centres, heterogeneous in study conduct, definitions, treatment protocols and study outcome reporting. Of the 24 included studies effective safety themes included medication reconciliation, decision support for prescribing medications, communication between teams, infection prevention and measures of EHR-specific harm. Heterogeneity of the interventions and study characteristics precluded a systematic meta-analysis. Most studies reported process measures and not patient-level safety outcomes: We found no or limited evidence in 13 of 14 predefined safety areas, with good evidence limited to medication safety.

CONCLUSIONS

Published evidence for EHR impact on safety outcomes from interventional studies is limited and does not permit firm conclusions regarding the full safety impact of EHRs or support recommendations about ideal design features. The review highlights the need for greater transparency in quality assurance of existing EHRs and further research into suitable metrics and study designs.

Uncovering differences in interoperability across hospital size

BACKGROUND

Small hospitals significantly lag behind large hospitals in interoperable health information exchange. This analysis identifies factors that explain differences in interoperability between these hospital types. We place a particular emphasis on such factors as number of functionalities within electronic health record system (EHR), participation in regional and national networks, and adoption of a dominant EHR.

METHODS

Using data from the 2017 American Hospital Association (AHA) Annual Survey Information Technology Supplement (n = 2789 hospitals), we applied a Blinder-Oaxaca decomposition technique to explain differences in each domain of interoperability. Interoperability is defined as a hospitals' ability to electronically send, receive, and integrate summary of care records into their EHR and electronically find patient health information from external sources.

RESULTS

The percentage of small and large hospitals engaged in each interoperability domain increased between 2015 and 2017; however, the gap between these hospital types remained mostly the same. Differences in characteristics explained most of the gap in integrating, finding and receiving the data while differences in characteristics and returns to characteristics were significant in explaining the differences in sending the data. The number of EHR functionalities and participation in national and regional networks were among largest contributors to the gap.

CONCLUSIONS

The lack of participation in multiple networks and the number of functionalities in EHRs among small hospitals are key factors that explain the difference in interoperability between small and large hospitals. Policies that incentivize these activities or simplify electronic exchange could reduce gaps in interoperability among hospitals of different sizes.

Evaluation of drug information resources for drug-ethanol and drug-tobacco interactions

OBJECTIVE

The research evaluated point-of-care drug interaction resources for scope, completeness, and consistency in drug-ethanol and drug-tobacco content.

METHODS

In a cross-sectional analysis, 2 independent reviewers extracted data for 108 clinically relevant interactions using 7 drug information resources (Clinical Pharmacology Drug Interaction Report, Facts & Comparisons eAnswers, Lexicomp Interactions, Micromedex Drug Interactions, Drug Interactions Analysis and Management, Drug Interaction Facts, and Stockley's Drug Interactions). Scope (presence of an entry), completeness (content describing mechanism, clinical effects, severity, level of certainty, and course of action for each present interaction; up to 1 point per assessed item for a total possible score of 5 points), and consistency (similarity among resources) were evaluated.

RESULTS

Fifty-three drug-ethanol and 55 drug-tobacco interactions were analyzed. Drug-ethanol interaction entries were most commonly present in Lexicomp (84.9%), Clinical Pharmacology (83.0%), and Stockley's Drug Interactions (73.6%), compared to other resources (p<0.05). Drug-tobacco interactions were more often covered in Micromedex (56.4%), Stockley's Drug Interactions (56.4%), Drug Interaction Facts (43.6%), and Clinical Pharmacology (41.8%) (p<0.001). Overall completeness scores were higher for Lexicomp, Micromedex, Drug Interaction Facts, and Facts & Comparisons (median 5/5 points, interquartile range [IQR] 5 to 5, p<0.001) for drug-ethanol and for Micromedex (median 5/5 points, IQR 5 to 5, p<0.05) for drug-tobacco, compared to other resources. Drug Interaction Facts and Micromedex were among the highest scoring resources for both drug-ethanol (73.7%, 68.6%) and drug-tobacco (75.0%, 32.3%) consistency.

CONCLUSIONS

Scope and completeness were high for drug-ethanol interactions, but low for drug-tobacco interactions. Consistency was highly variable across both interaction types.

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.