Estimating the information gap between emergency department records of community medication compared to on-line access to the community-based pharmacy records

Clinical Pharmacy Services Enhanced by Electronic Health Record (EHR) Access: An Innovation Narrative

BACKGROUND

Patient care in the community pharmacy setting is often hindered due to limited access to adequate patient health information (PHI). Various studies suggest that lack of access to PHI is a main reason for delay in pharmaceutical care, medication dispensing errors, and lacking interprofessional relationships between prescribers and pharmacists. Literature has shown that interprofessional collaboration and improved access to PHI can improve transitions of care and communication for pharmacists, but literature is sparse on implementation of electronic health record (HER) access within independent community pharmacies.

METHODS

This observational study follows implementation of HER access into a rural community pharmacy to enhance common clinical services carried out by pharmacy staff. Metrics include number of enhanced consultations by pharmacy staff, type of consultations provided, potential reimbursement, decreased need to follow up with other providers, potential for decreased time to treatment or refills, and aspects of EHR most utilized during search.

RESULTS

Two-hundred sixty three patients' profiles were assessed, with 164 (62.4%) deemed appropriate for EHR access and searching. Most interventions made were related to cardiovascular, endocrinologic, neuropsychiatric, and COVID-19 therapy medications.

CONCLUSION

EHR access in community pharmacy has the potential to improve both the quality and availability of clinical patient interventions through enhanced knowledge of PHI.

Risk factors for clinically relevant deviations in patients' medication lists reported by patients in personal health records: a prospective cohort study in a hospital setting

Background Personal health records have the potential to identify medication discrepancies. Although they facilitate patient empowerment and broad implementation of medication reconciliation, more medication discrepancies are identified through medication reconciliation performed by healthcare professionals. Aim We aimed to identify the factors associated with the occurrence of a clinically relevant deviation in a patient’s medication list based on a personal health record (used by patients) compared to medication reconciliation performed by a healthcare professional. Method Three- to 14 days prior to a planned admission to the Cardiology-, Internal Medicine- or Neurology Departments, at Amphia Hospital, Breda, the Netherlands, patients were invited to update their medication file in their personal health records. At admission, medication reconciliation was performed by a pharmacy technician. Deviations were determined as differences between these medication lists. Associations between patient-, setting-, and medication-related factors, and the occurrence of a clinically relevant deviation (National Coordinating Council for Medication Error Reporting and Prevention class \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\ge$$\end{document}≥ E) were analysed. Results Of the 488 patients approached, 155 patients were included. Twenty-four clinically relevant deviations were observed. Younger patients (adjusted odds ratio (aOR) 0.94; 95%CI:0.91–0.98), patients who used individual multi-dose packaging (aOR 14.87; 95%CI:2.02–110), and patients who used \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\ge$$\end{document}≥ 8 different medications, were at highest risk for the occurrence of a clinically relevant deviation (sensitivity 0.71; specificity 0.62; area under the curve 0.64 95%CI:0.52–0.76). Conclusion Medication reconciliation is the preferred method to identify medication discrepancies for patients with individual multi-dose packaging, and patients who used eight or more different medications.

Digital Applications Targeting Medication Safety in Ambulatory High-Risk CKD Patients: Randomized Controlled Clinical Trial

BACKGROUND AND OBJECTIVES

Patients with CKD are at risk for adverse drug reactions, but effective community-based preventive programs remain elusive. In this study, we compared the effectiveness of two digital applications designed to improve outpatient medication safety.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

In a 1-year randomized controlled trial, 182 outpatients with advanced CKD were randomly assigned to receive a smartphone preloaded with either eKidneyCare (n=89) or MyMedRec (n=93). The experimental intervention, eKidneyCare, includes a medication feature that prompted patients to review medications monthly and report changes, additions, or medication problems to clinicians for reconciliation and early intervention. The active comparator was MyMedRec, a commercially available, standalone application for storing medication and other health information that can be shared with patients' providers. The primary outcome was the rate of medication discrepancy, defined as differences between the patient's reported history and the clinic's medication record, at exit.

RESULTS

At exit, the eKidneyCare group had fewer total medication discrepancies compared with MyMedRec (median, 0.45; interquartile range, 0.33-0.63 versus 0.67; interquartile range, 0.40-1.00; P=0.001), and the change from baseline was 0.13±0.27 in eKidneyCare and 0.30±0.41 in MyMedRec (P=0.007). eKidneyCare use also reduced the severity of clinically relevant medication discrepancies in all categories, including those with the potential to cause serious harm (estimated rate ratio, 0.40; 95% confidence interval, 0.27 to 0.63). Usage data revealed that 72% of patients randomized to eKidneyCare completed one or more medication reviews per month, whereas only 30% of patients in the MyMedRec group (adjusted for dropouts) kept their medication profile on their phone.

CONCLUSIONS

In patients who are high risk and have CKD, eKidneyCare significantly reduced the rate and severity of medication discrepancies, the proximal cause of medication errors, compared with the active comparator. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER: www.ClinicalTrials.gov, NCT:02905474.

Incidence and Variables Associated With Inconsistencies in Opioid Prescribing at Hospital Discharge and Its Associated Adverse Drug Outcomes

OBJECTIVES

Opioid-related medication errors (MEs) can have a significant impact on patient health and contribute to opioid misuse. The objective of this study was to estimate the incidence of and variables associated with the receipt of an opioid prescription and opioid-related MEs (omissions, duplications, or dose changes) at hospital discharge. We also determined rates of adverse drug events and risks of emergency department visits, readmissions, or death 30 days and 90 days post discharge associated with MEs.

METHODS

A cohort of hospitalized patients discharged from the McGill University Health Centre between 2014 and 2016 was assembled. The impact of opioid-related MEs was assessed in a propensity score-adjusted logistic regression models. Multivariable logistic regression was used to determine characteristics associated with MEs and discharge opioid prescription.

RESULTS

A total of 1530 (43.9%) of 3486 patients were prescribed opioids, of which 13.4% (n = 205) of patients had at least 1 opioid-related ME. Rates of MEs were higher in handwritten prescriptions compared to the electronic reconciliation discharge prescription group (20.6% vs 1.2%). Computer-based prescriptions were associated with a 69% lower risk of opioid-related MEs (adjusted odds ratio: 0.31, 95% confidence interval: 0.14-0.65) as well as 63% lower risk of receiving an opioid prescription. Opioid-related MEs were associated with a 2.3 times increased risk of healthcare utilization in the 30 days postdischarge period (adjusted odds ratio: 2.32, 95% confidence interval: 1.24-4.32).

CONCLUSIONS

Opioid-related MEs are common in handwritten discharge prescriptions. Our findings highlight the need for computer-based prescribing platforms and careful review of medications during critical periods of care such as hospital transitions.

Failure to follow medication changes made at hospital discharge is associated with adverse events in 30 days

OBJECTIVE

To evaluate the hypothesis that nonadherence to medication changes made at hospital discharge is associated with an increased risk of adverse events in the 30 days postdischarge.

STUDY SETTING

Patients admitted to hospitals in Montreal, Quebec, between 2014 and 2016.

STUDY DESIGN

Prospective cohort study.

DATA COLLECTION

Nonadherence to medication changes was measured by comparing medications dispensed in the community with those prescribed at hospital discharge. Patient, health system, and drug regimen-level covariates were measured using medical services and pharmacy claims data as well as data abstracted from the patient's hospital chart. Multivariable Cox models were used to determine the association between nonadherence to medication changes and the risk of adverse events.

PRINCIPAL FINDINGS

Among 2655 patients who met our inclusion criteria, mean age was 69.5 years (SD 14.7) and 1581 (60%) were males. Almost half of patients (n = 1161, 44%) were nonadherent to at least one medication change, and 860 (32%) were readmitted to hospital, visited the emergency department, or died in the 30 days postdischarge. Patients who were not adherent to any of their medication changes had a 35% higher risk of adverse events compared to those who were adherent to all medication changes (1.41 vs 1.27 events/100 person-days, adjusted hazard ratio: 1.35, 95% CI: 1.06-1.71).

CONCLUSIONS

Almost half of all patients were not adherent to some or all changes made to their medications at hospital discharge. Nonadherence to all changes was associated with an increased risk of adverse events. Interventions addressing barriers to adherence should be considered moving forward.

Both New and Chronic Potentially Inappropriate Medications Continued at Hospital Discharge Are Associated With Increased Risk of Adverse Events

BACKGROUND

Admission to hospital provides the opportunity to review patient medications; however, the extent to which the safety of drug regimens changes after hospitalization is unclear.

OBJECTIVE

To estimate the number of potentially inappropriate medications (PIMs) prescribed to patients at hospital discharge and their association with the risk of adverse events 30 days after discharge.

DESIGN

Prospective cohort study.

SETTING

Tertiary care hospitals within the McGill University Health Centre Network in Montreal, Quebec, Canada.

PARTICIPANTS

Patients from internal medicine, cardiac, and thoracic surgery, aged 65 years and older, admitted between October 2014 and November 2016.

MEASURES

Abstracted chart data were linked to provincial health databases. PIMs were identified using AGS (American Geriatrics Society) Beers Criteria®, STOPP, and Choosing Wisely statements. Multivariable logistic regression and Cox models were used to assess the association between PIMs and adverse events.

RESULTS

Of 2,402 included patients, 1,381 (57%) were male; median age was 76 years (interquartile range [IQR] = 70‐82 years); and eight discharge medications were prescribed (IQR = 2‐8). A total of 1,576 (66%) patients were prescribed at least one PIM at discharge; 1,176 (49%) continued a PIM from prior to admission, and 755 (31%) were prescribed at least one new PIM. In the 30 days after discharge, 218 (9%) experienced an adverse drug event (ADE) and 862 (36%) visited the emergency department (ED), were rehospitalized, or died. After adjustment, each additional new PIM and continued community PIM were respectively associated with a 21% (odds ratio [OR] = 1.21; 95% confidence interval [CI] = 1.01‐1.45) and a 10% (OR = 1.10; 95% CI = 1.01‐1.21) increased odds of ADEs. They were also respectively associated with a 13% (hazard ratio [HR] = 1.13; 95% CI = 1.03‐1.26) and a 5% (HR = 1.05; 95% CI = 1.00‐1.10) increased risk of ED visits, rehospitalization, and death.

CONCLUSIONS

Two in three hospitalized patients were prescribed a PIM at discharge, and increasing numbers of PIMs were associated with an increased risk of ADEs and all‐cause adverse events. Improving hospital prescribing practices may reduce the frequency of PIMs and associated adverse events. J Am Geriatr Soc 68:1184–1192, 2020.

See related editorial by Donna M. Fick in this issue.

Medication Reconciliation Improvement Utilizing Process Redesign and Clinical Decision Support

BACKGROUND

Despite years of attention, hospitals continue to struggle to implement successful medication reconciliation. This study aimed to increase the percentage of hospital admission medication reconciliation (AdmMedRec) completion to ≥ 95% in 12 months at a large academic children's hospital.

METHODS

A quality improvement (QI) project was initiated in April 2017 by an interdisciplinary team of physicians, nurses, pharmacists, and analysts, co-led by a pediatric hospitalist and chief medical information officer. Interventions were implemented through sequential Plan-Do-Study-Act cycles. Process maps, fishbone diagrams, and failure mode and effects analysis were used to identify AdmMedRec failures. Baseline data from 12,481 admission encounters July 2016-April 2017 were analyzed. Interventions included electronic health record (EHR) workflow redesign, clarification of clinicians' responsibilities, targeted training, Best Practice Advisory alert, and weekly reporting of specialty- and physician-specific performance data. Data from 13,082 postintervention period admission encounters were examined. Reconciliation by therapeutic drug classes was calculated as a proxy for quality.

RESULTS

AdmMedRec completion rate increased from a baseline of 73% to 95% within 7 months from the start of this project and was sustained at 94% during the postintervention period. Psychiatry and hospital medicine demonstrated the largest improvements, with rates increasing from 17% to 88% and 76% to 98%, respectively. Percentages of reconciled medications in all 13 therapeutic classes, including high-risk drugs, improved significantly (p < 0.05).

CONCLUSIONS

Using an interdisciplinary team and interventions focused on process and culture changes, this QI initiative was successful at increasing AdmMedRec rates and reducing omission errors across all therapeutic drug classes.

Challenges at Care Transitions: Failure to Follow Medication Changes Made at Hospital Discharge

BACKGROUND

In-hospital medication reconciliation has not demonstrated reductions in adverse health outcomes, possibly because patients do not follow the changes made to their preadmission medications. Our objective was to determine the incidence of and variables associated with failure to follow newly prescribed therapies, discontinued medications, and dose changes.

METHODS

A prospective cohort study of patients admitted to hospitals in Montreal, Quebec between 2014 and 2016 was conducted. Failure to follow medication changes 30 days post discharge was measured by comparing prescribed and dispensed medications. Multivariable logistic regression was used to determine characteristics associated with failure to follow changes.

RESULTS

Among 2655 patients, mean age was 69.5 years (SD 14.7), and 1581 (60%) were males. There were 10,068 medication changes made at hospital discharge and 24% were not followed in the 30 days post discharge. Thirty percent of dose modifications were filled at the incorrect dose, 27% of new medications were not filled, and 12% of discontinued medications were filled. A number of factors increased the risk of failure to follow medication changes, including increasing out-of-pocket medication costs (adjusted odds ratio [aOR] 1.12; 95% confidence interval [CI], 1.07-1.18), discharge to long-term care facility (aOR 2.29; 95% CI, 1.63-3.08), and not having medications dispensed prior to admission (aOR 4.67; 95% CI, 3.75-5.90).

CONCLUSION

One in 4 hospital medication changes was not followed post discharge. Health policy aimed at eliminating out-of-pocket medication costs and investigation of factors influencing failure to follow changes for those not dispensed medications prior to admission and for long-term care residents are important next steps to address this issue.

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.

How complete is the information on preadmission psychotropic medications in inpatients with dementia? A comparison of hospital medical records with dispensing data

OBJECTIVES

Reliable information on preadmission medications is essential for inpatients with dementia, but its quality has hardly been evaluated. We assessed the completeness of information and factors associated with incomplete recording.

METHODS

We compared preadmission medications recorded in hospital electronic medical records (EMRs) with community-pharmacy dispensations in hospitalizations with discharge code for dementia at the University Hospital of Udine, Italy, 2012-2014. We calculated: (a) prevalence of omissions (dispensed medication not recorded in EMRs), additions (medication recorded in EMRs not dispensed), and discrepancies (any omission or addition); (b) multivariable logistic regression odds ratio, with 95% confidence interval (95% CI), of ≥1 omission.

RESULTS

Among 2,777 hospitalizations, 86.1% had ≥1 discrepancy for any medication (Kappa 0.10) and 33.4% for psychotropics. When psychotropics were recorded in EMR, antipsychotics were added in 71.9% (antidepressants: 29.2%, antidementia agents: 48.2%); when dispensed, antipsychotics were omitted in 54.4% (antidepressants: 52.7%, antidementia agents: 41.5%). Omissions were 92% and twice more likely in patients taking 5 to 9 and ≥10 medications (vs. 0 to 4), 17% in patients with psychiatric disturbances (vs. none), and 41% with emergency admission (vs. planned).

CONCLUSION

Psychotropics, commonly used in dementia, were often incompletely recorded. To enhance information completeness, both EMRs and dispensations should be used.

Accuracy of medication information sources compared to the best possible medication history for patients presenting to the emergency department

OBJECTIVE

To assess the accuracy of medication information sources available for adult patients presenting to the ED, compared to a best possible medication history (BPMH).

METHODS

This prospective observational study was undertaken in the ED of a major tertiary-referral teaching hospital. A convenience sample of consecutive adult patients taking one or more regular medications was included. A BPMH was ascertained using patient/carer interviews, where available, and confirmed with one or more other sources. For residential care facility (RCF) patients, the RCF medication chart and at least one other source were used. Information sources compared with the BPMH were community pharmacy dispensing history, patient's own medications, patient's medication list, general practitioner letter, medications stored in and labelled on dose administration aids (DAAs) and the RCF chart. Number of discrepancies per patient for each source was determined by comparing medications and dose regimens to those documented in the BPMH.

RESULTS

A total of 455 patients (median age 71 years) took a median of six 'regular' and two 'as required' medications. The median number (range) of discrepancies per patient for regular medication names and dosages were RCF chart 0 (0-3), DAA contents 2.0 (0-9), patient's medication list 2.5 (0-16), DAA medications label 3.0 (0-7), community pharmacy history 3.0 (0-19), general practitioner letter 3.0 (0-18) and patient's own medications 4.0 (0-16). Overall, 40.4% of discrepancies were deemed 'moderate' or 'high' clinical significance. Omission errors accounted for 55.6% of discrepancies.

CONCLUSIONS

A combination of sources is essential to determine the BPMH. RCF charts provided the most accurate information. Other sources had two to four regular medication-related discrepancies per patient.

The pharmacist and the EHR

The adoption of electronic health records (EHRs) across the United States has impacted the methods by which health care professionals care for their patients. It is not always recognized, however, that pharmacists also actively use advanced functionality within the EHR. As critical members of the health care team, pharmacists utilize many different features of the EHR. The literature focuses on 3 main roles: documentation, medication reconciliation, and patient evaluation and monitoring. As health information technology proliferates, it is imperative that pharmacists' workflow and information needs are met within the EHR to optimize medication therapy quality, team communication, and patient outcomes.

Potential benefit of electronic pharmacy claims data to prevent medication history errors and resultant inpatient order errors

OBJECTIVE

We sought to assess the potential of a widely available source of electronic medication data to prevent medication history errors and resultant inpatient order errors.

METHODS

We used admission medication history (AMH) data from a recent clinical trial that identified 1017 AMH errors and 419 resultant inpatient order errors among 194 hospital admissions of predominantly older adult patients on complex medication regimens. Among the subset of patients for whom we could access current Surescripts electronic pharmacy claims data (SEPCD), two pharmacists independently assessed error severity and our main outcome, which was whether SEPCD (1) was unrelated to the medication error; (2) probably would not have prevented the error; (3) might have prevented the error; or (4) probably would have prevented the error.

RESULTS

Seventy patients had both AMH errors and current, accessible SEPCD. SEPCD probably would have prevented 110 (35%) of 315 AMH errors and 46 (31%) of 147 resultant inpatient order errors. When we excluded the least severe medication errors, SEPCD probably would have prevented 99 (47%) of 209 AMH errors and 37 (61%) of 61 resultant inpatient order errors. SEPCD probably would have prevented at least one AMH error in 42 (60%) of 70 patients.

CONCLUSION

When current SEPCD was available for older adult patients on complex medication regimens, it had substantial potential to prevent AMH errors and resultant inpatient order errors, with greater potential to prevent more severe errors. Further study is needed to measure the benefit of SEPCD in actual use at hospital admission.

Medical History of Elderly Patients in the Emergency Setting: Not an Easy Point-of-Care Diagnostic Marker

Background. Medical histories are a crucially important diagnostic tool. Elderly patients represent a large and increasing group of emergency patients. Due to cognitive deficits, taking a reliable medical history in this patient group can be difficult. We sought to evaluate the medical history-taking in emergency patients above 75 years of age with respect to duration and completeness. Methods. Anonymous data of consecutive patients were recorded. Times for the defined basic medical history-taking were documented, as were the availability of other sources and times to assess these. Results. Data of 104 patients were included in the analysis. In a quarter of patients (25%, n = 26) no complete basic medical history could be obtained. In the group of patients where complete data could be gathered, only 16 patients were able to provide all necessary information on their own. Including other sources like relatives or GPs prolonged the time until complete medical history from 7.3 minutes (patient only) to 26.4 (+relatives) and 56.3 (+GP) minutes. Conclusions. Medical histories are important diagnostic tools in the emergency setting and are prolonged in the elderly, especially if additional documentation and third parties need to be involved. New technologies like emergency medical cards might help to improve the availability of important patient data but implementation of these technologies is costly and faces data protection issues.

[Reliability of Primary Care computerised medication records]

OBJECTIVE

To quantify and to evaluate the reliability of Primary Care (PC) computerised medication records of as an information source of patient chronic medications, and to identify associated factors with the presence of discrepancies.

DESIGN

A descriptive cross-sectional study.

LOCATION

General Referral Hospital in Murcia.

PARTICIPANTS

Patients admitted to the cardiology-chest diseases unit, during the months of February to April 2013, on home treatment, who agreed to participate in the study.

MAIN MEASUREMENTS

Evaluation of the reliability of Primary Care computerised medication records by analysing the concordance, by identifying discrepancies, between the active medication in these records and that recorded in pharmacist interview with the patient/caregiver. Identification of associated factors with the presence of discrepancies was analysed using a multivariate logistic regression.

RESULTS

The study included a total of 308 patients with a mean of 70.9 years (13.0 SD). The concordance of active ingredients was 83.7%, and this decreased to 34.7% when taking the dosage into account. Discrepancies were found in 97.1% of patients. The most frequent discrepancy was omission of frequency (35.6%), commission (drug added unjustifiably) (14.6%), and drug omission (12.7%). Age older than 65 years (1.98 [1.08 to 3.64]), multiple chronic diseases (1.89 [1.04 to 3.42]), and have a narcotic or psychotropic drug prescribed (2.22 [1.16 to 4.24]), were the factors associated with the presence of discrepancies.

CONCLUSIONS

Primary Care computerised medication records, although of undoubted interest, are not be reliable enough to be used as the sole source of information on patient chronic medications when admitted to hospital.

Provider and Patient Perceptions of an External Medication History Function

OBJECTIVES

To determine the awareness and use of an external medication history (EMH) function within an electronic health record and its impact on patient perception of medication adherence.

METHODS

Two self-administered surveys were given: one to providers and one to patients. Participants included providers from an academic medical center and patients from 2 general internal medicine clinics.

RESULTS

Of 154 completed provider surveys, 61% were aware the EMH existed. More of the respondents aware of the EMH were primary care and medicine subspecialty providers (79.1%) when compared with surgical providers (20.9%, P < 0.0001). The most common reasons chosen for looking at the EMH included checking for medication adherence (44%), questions about a specific medication (40%), and checking controlled substance prescription history (37%). Of those aware of the EMH, 65% found medications on the EMH that they were not aware their patient was getting filled. Of the 94 patient surveys, 34% felt the EMH feature might change their medication taking behavior, and 48% responded that it already had. Patients with a history of depression and/or anxiety were less likely to report the intent to change their medication taking behavior, OR, 0.34 [95% CI, 0.13-0.87].

CONCLUSION

An external medication history function can provide further insight about a patient's medication profile and prescription filling. Knowledge attained from the EMH may improve patient safety by helping to uncover nonadherence, dosing discrepancies, and medications prescribed by other providers. Additionally, patient knowledge of this feature might improve medication adherence. Although further studies are needed to obtain objective data, the external medication history function may have significant impact on both providers and patients, and its benefit should be widely publicized.

Challenges to the implementation of a nationwide electronic prescribing network in primary care: a qualitative study of users' perceptions

BACKGROUND AND OBJECTIVE

The objective of this study was to identify physicians' and pharmacists' perceptions of the challenges and benefits to implementing a nationwide electronic prescribing network linking medical clinics and community pharmacies in Quebec, Canada.

METHODS

Forty-nine people (12 general practitioners, 2 managers, 33 community pharmacists, and 2 pharmacy staff members) from 40 points of care (10 primary care clinics (42% of all the connected sites) and 30 community pharmacies (44%)) were interviewed in 2013. Verbatim transcripts were analyzed using thematic analysis.

RESULTS

A low level of network use was observed. Most pharmacists processed e-prescriptions by manual entry instead of importing electronically. They reported concerns about potential errors generated by importing e-prescriptions, mainly due to the instruction field. Paper prescriptions were still perceived as the best means for safe and effective processing of prescriptions in pharmacies. Speed issues when validating e-prescription messages were seen as an irritant by physicians, and resulted in several of them abandoning transmission. Displaying the medications based on the dispensing data was identified as the main obstacle to meaningful use of medication histories.

CONCLUSIONS

Numerous challenges impeded realization of the benefits of this network. Standards for e-prescription messages, as well as rules for message validation, need to be improved to increase the potential benefits of e-prescriptions. Standard drug terminology including the concept of clinical medication should be developed, and the implementation of rules in local applications to allow for the classification and reconciliation of medication lists from dispensing data should be made a priority.

Accuracy of Electronic Medical Record Medication Reconciliation in Emergency Department Patients

BACKGROUND

Medication history discrepancies have the potential to cause significant adverse clinical effects for patients. More than 40% of medication errors can be traced to inadequate reconciliation.

OBJECTIVE

The objective of this study was to determine the accuracy of electronic medical record (EMR)-reconciled medication lists obtained in an academic emergency department (ED).

METHODS

Comprehensive research medication ingestion histories for the 48 h preceding ED visit were performed and compared to reconciled EMR medication lists in a convenience sample of ED patients. The reconciled EMR list of prescription, nonprescription, vitamins, herbals, and supplement medications were compared against a structured research medication history tool. We measured the accuracy of the reconciled EMR list vs. the research history for all classes of medications as the primary outcome.

RESULTS

Five hundred and two subjects were enrolled. The overall accuracy of EMR-recorded ingestion histories in the preceding 48 h was poor. The EMR was accurate in only 21.9% of cases. Neither age ≥ 65 years (odds ratio [OR] = 1.3; 95% confidence interval [CI] 0.6-2.6) nor sex (female vs. male: OR = 1.5; 95% CI 0.9-2.5) were predictors of accurate EMR history. In the inaccurate EMRs, prescription lists were more likely to include medications that the subject did not report using (78.9%), while the EMR was more likely not to capture nonprescriptions (76.1%), vitamins (73.0%), supplements (67.3%), and herbals (89.1%) that the subject reported using.

CONCLUSIONS

Medication ingestion histories procured through triage EMR reconciliation are often inaccurate, and additional strategies are needed to obtain an accurate list.

Implementation of a shared medication list: physicians' views on availability, accuracy and confidentiality

BACKGROUND

Physicians, patients and others involved need to have accurate information on patients' current drug prescriptions available, and have that information protected from unauthorized access. During the past decade, many counties in Sweden have implemented regionally shared medication lists within health care.

OBJECTIVE

The aim of this study was to describe physicians' views on changes in accuracy, availability and confidentiality in the transition from local medication lists to a regionally shared medication list.

SETTING

Health care units in four different counties of Sweden after the transition from local medication lists to a regionally shared medication list. The shared medication list was an integrated part of the electronic health record system in the respective counties, but the system and implementation process varied.

METHODS

Physicians (n = 7) with experience of transition from local medication lists to a regionally shared medication list were interviewed in a semi-structured manner.

MAIN OUTCOME MEASURE

Physicians' views on changes in information risks, focusing on accuracy, availability and confidentiality. Results The transition from local medication lists to a shared medication list increased the availability of information: from being time consuming or not possible to access from other care givers to most information being available in one place. A regionally shared medication list was perceived as having the potential to provide a greater accuracy of information, but not always: the shared medication list was perceived as more complete but with more non-current drugs. On the other hand, a shared medication list implied an increased risk of violating patient privacy, placing greater demands on IT security in order to protect the confidentiality of information.

CONCLUSION

Physicians perceived a regionally shared medication list to increase the availability of information about current prescriptions and potentially the accuracy but may decrease the confidentiality of information. To implement a shared medication list, we recommend providing clear description of responsibilities and routines for normal activities as well as back-up routines, consider IT-security and data protection early, involve patients to improve the accuracy of the list as well as to monitor and evaluate the implementation.