How patients can improve the accuracy of their medical records

Smoking data quality of primary care practices in comparison with smoking data from the New Zealand Māori and Pacific abdominal aortic aneurysm screening programme: an observational study

BACKGROUND

Quality smoking data is crucial for assessing smoking-related health risk and eligibility for interventions related to that risk. Smoking information collected in primary care practices (PCPs) is a major data source; however, little is known about the PCP smoking data quality. This project compared PCP smoking data to that collected in the Māori and Pacific Abdominal Aortic Aneurysm (AAA) screening programme.

METHODS

A two stage review was conducted. In Stage 1, data quality was assessed by comparing the PCP smoking data recorded close to AAA screening episodes with the data collected from participants at the AAA screening session. Inter-rater reliability was analysed using Cohen's kappa scores. In Stage 2, an audit of longitudinal smoking status was conducted, of a subset of participants potentially misclassified in Stage 1. Data were compared in three groups: current smoker (smoke at least monthly), ex-smoker (stopped > 1 month ago) and never smoker (smoked < 100 cigarettes in lifetime).

RESULTS

Of the 1841 people who underwent AAA screening, 1716 (93%) had PCP smoking information. Stage 1 PCP smoking data showed 82% concordance with the AAA data (adjusted kappa 0.76). Fewer current or ex-smokers were recorded in PCP data. In the Stage 2 analysis of discordant and missing data (N = 313), 212 were enrolled in the 29 participating PCPs, and of these 13% were deceased and 41% had changed PCP. Of the 93 participants still enrolled in the participating PCPs, smoking status had been updated for 43%. Data on quantity, duration, or quit date of smoking were largely missing in PCP records. The AAA data of ex-smokers who were classified as never smokers in the Stage 2 PCP data (N = 27) showed a median smoking cessation duration of 32 years (range 0-50 years), with 85% (N = 23) having quit more than 15 years ago.

CONCLUSIONS

PCP smoking data quality compared with the AAA data is consistent with international findings. PCP data captured fewer current and ex-smokers, suggesting ongoing improvement is important. Intervention programmes based on smoking status should consider complementary mechanisms to ensure eligible individuals are not missed from programme invitation.

Japanese Consumers' Attitudes towards Obtaining and Sharing Health Information Regarding Over-the-Counter Medication: Designing an Over-the-Counter Electronic Health Record

Designing an over-the-counter medication electronic health record (OTC-EHR) may help improve OTC usage. An online survey for the conceptual OTC-EHR design examined participant characteristics, attitudes towards obtaining user-shared OTC medication information, health-related application usage, and the inclination to share anonymized health information. Descriptive statistics, tests to assess statistical significance, and text mining were used to analyze the results. The findings revealed that Japanese consumers, particularly those with high eHealth literacy and women, possess relatively positive attitudes towards obtaining user-shared OTC medication information than those with low eHealth literacy (t (280.71) = -4.11, p < 0.001) and men (t (262.26) = -2.78, p = 0.006), respectively. Most consumers own smartphones but do not use health-related applications. A minority held positive attitudes about sharing anonymized health information. The perceived helpfulness of OTC-EHR was positively associated with the usage of health-related applications (χ² (4) = 18.35, p = 0.001) and attitude towards sharing anonymized health information (χ² (3) = 19.78, p < 0.001). The study findings contribute towards OTC-EHR's design to enhance consumers' self-medication and reduce risks, while the psychological barriers to sharing anonymized health information should be improved by increasing the OTC-EHR's penetration rate and engaging in appropriate information design.

Patients Managing Their Medical Data in Personal Electronic Health Records: Scoping Review

BACKGROUND

Personal electronic health records (PEHRs) allow patients to view, generate, and manage their personal and medical data that are relevant across illness episodes, such as their medications, allergies, immunizations, and their medical, social, and family health history. Thus, patients can actively participate in the management of their health care by ensuring that their health care providers have an updated and accurate overview of the patients' medical records. However, the uptake of PEHRs remains low, especially in terms of patients entering and managing their personal and medical data in their PEHR.

OBJECTIVE

This scoping review aimed to explore the barriers and facilitators that patients face when deciding to review, enter, update, or modify their personal and medical data in their PEHR. This review also explores the extent to which patient-generated and -managed data affect the quality and safety of care, patient engagement, patient satisfaction, and patients' health and health care services.

METHODS

We searched the MEDLINE, Embase, CINAHL, PsycINFO, Cochrane Library, Web of Science, and Google Scholar web-based databases, as well as reference lists of all primary and review articles using a predefined search query.

RESULTS

Of the 182 eligible papers, 37 (20%) provided sufficient information about patients' data management activities. The results showed that patients tend to use their PEHRs passively rather than actively. Patients refrain from generating and managing their medical data in a PEHR, especially when these data are complex and sensitive. The reasons for patients' passive data management behavior were related to their concerns about the validity, applicability, and confidentiality of patient-generated data. Our synthesis also showed that patient-generated and -managed health data ensures that the medical record is complete and up to date and is positively associated with patient engagement and patient satisfaction.

CONCLUSIONS

The findings of this study suggest recommendations for implementing design features within the PEHR and the construal of a dedicated policy to inform both clinical staff and patients about the added value of patient-generated data. Moreover, clinicians should be involved as important ambassadors in informing, reminding, and encouraging patients to manage the data in their PEHR.

What do primary care staff think about patients accessing electronic health records? A focus group study

BACKGROUND

Patients have expressed a growing interest in having easy access to their personal health information, and internationally there has been increasing policy focus on patient and care records being more accessible. Limited research from the UK has qualitatively explored this topic from the primary care staff perspective. This study aimed to understand what primary care staff think about patients accessing electronic health records, highlighting errors in electronic health records, and providing feedback via online patient portals.

METHODS

A focus group study involving 19 clinical and non-clinical primary care staff. Primary care practices were purposively sampled based on practice size and the percentage of patients using online services. Data were analysed inductively using reflexive thematic analysis.

RESULTS

Three themes were generated: (1) Information - what, why and when? (2) Changing behaviours and protecting relationships, and (3) Secure access and safeguarding. The emotional considerations and consequences for staff and patients featured prominently in the data as an overarching theme.

CONCLUSIONS

Primary care staff described being invested and supportive of patients accessing their electronic health records, and acknowledged the numerous potential benefits for safety. Uncertainty around the parameters of access, the information available and what this might look like in the future, processes for patients highlighting errors in records, relational issues, security and safeguarding and equitable access, were key areas warranting examination in future research.

Prevalence and Factors Associated with Patient-Requested Corrections to the Medical Record through Use of a Patient Portal: Findings from a National Survey

BACKGROUND

Providing patients with medical records access is one strategy that health systems can utilize to reduce medical errors. However, how often patients request corrections to their records on a national scale is unknown.

OBJECTIVES

We aimed to develop population-level estimates of patients who request corrections to their medical records using national-level data. We also identified patient-level correlates of requesting corrections.

METHODS

We used the 2017 and 2019 Health Information National Trends Survey and examined all patient portal adopters. We applied jackknife replicate weights to develop population-representative estimates of the prevalence of requesting medical record corrections. We conducted a multivariable logistic regression analysis to identify correlates of requesting corrections while controlling for demographic factors, health care utilization patterns, health status, technology/internet use patterns, and year.

RESULTS

Across 1,657 respondents, 125 (weighted estimate: 6.5%) reported requesting corrections to their medical records. In unadjusted models, greater odds of requesting corrections were observed among patients who reported their race/ethnicity as non-Hispanic black (odds ratio [OR]: 2.20, 95% confidence interval [CI]: 1.10-4.43), had frequent portal visits (OR: 3.92, 95% CI: 1.51-10.23), and had entered data into the portal (OR: 7.51, 95% CI: 4.08-13.81). In adjusted models, we found greater odds of requesting corrections among those who reported frequent portal visits (OR: 3.39, 95% CI: 1.24-9.33) and those who reported entering data into the portal (OR: 6.43, 95% CI: 3.20-12.94). No other significant differences were observed.

CONCLUSION

Prior to the Information Blocking Final Rule in April 2021, approximately 6.5% of patients requested corrections of errors in their medical records at the national level. Those who reported higher engagement with their health, as proxied by portal visit frequency and entering data into the portal, were more likely to request corrections.

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.

Interventions to increase patient portal use in vulnerable populations: a systematic review

BACKGROUND

More than 100 studies document disparities in patient portal use among vulnerable populations. Developing and testing strategies to reduce disparities in use is essential to ensure portals benefit all populations.

OBJECTIVE

To systematically review the impact of interventions designed to: (1) increase portal use or predictors of use in vulnerable patient populations, or (2) reduce disparities in use.

MATERIALS AND METHODS

A librarian searched Ovid MEDLINE, EMBASE, CINAHL, and Cochrane Reviews for studies published before September 1, 2018. Two reviewers independently selected English-language research articles that evaluated any interventions designed to impact an eligible outcome. One reviewer extracted data and categorized interventions, then another assessed accuracy. Two reviewers independently assessed risk of bias.

RESULTS

Out of 18 included studies, 15 (83%) assessed an intervention's impact on portal use, 7 (39%) on predictors of use, and 1 (6%) on disparities in use. Most interventions studied focused on the individual (13 out of 26, 50%), as opposed to facilitating conditions, such as the tool, task, environment, or organization (SEIPS model). Twelve studies (67%) reported a statistically significant increase in portal use or predictors of use, or reduced disparities. Five studies (28%) had high or unclear risk of bias.

CONCLUSION

Individually focused interventions have the most evidence for increasing portal use in vulnerable populations. Interventions affecting other system elements (tool, task, environment, organization) have not been sufficiently studied to draw conclusions. Given the well-established evidence for disparities in use and the limited research on effective interventions, research should move beyond identifying disparities to systematically addressing them at multiple levels.

Improving Primary Care Medication Processes by Using Shared Electronic Medication Plans in Switzerland: Lessons Learned From a Participatory Action Research Study

Background

Several countries have launched health information technology (HIT) systems for shared electronic medication plans. These systems enable patients and health care professionals to use and manage a common list of current medications across sectors and settings. Shared electronic medication plans have great potential to improve medication management and patient safety, but their integration into complex medication-related processes has proven difficult, and there is little scientific evidence to guide their implementation.

Objective

The objective of this paper is to summarize lessons learned from primary care professionals involved in a pioneering pilot project in Switzerland for the systemwide implementation of shared electronic medication plans. We collected experiences, assessed the influences of the local context, and analyzed underlying mechanisms influencing the implementation.

Methods

In this formative action research study, we followed 5 clusters of health care professionals during 6 months. The clusters represented rural and urban primary care settings. A total of 18 health care professionals (primary care physicians, pharmacists, and nurses) used the pilot version of a shared electronic medication plan on a secure web platform, the precursor of Switzerland’s electronic patient record infrastructure. We undertook 3 group interviews with each of the 5 clusters, analyzed the content longitudinally and across clusters, and summarized it into lessons learned.

Results

Participants considered medication plan management, digitalized or not, a core element of good clinical practice. Requirements for the successful implementation of a shared electronic medication plan were the integration into and simplification of clinical routines. Participants underlined the importance of an enabling setting with designated reference professionals and regular high-quality interactions with patients. Such a setting should foster trusting relationships and nurture a culture of safety and data privacy. For participants, the HIT was a necessary but insufficient building block toward better interprofessional communication, especially in transitions. Despite oral and written information, the availability of shared electronic medication plans did not generate spontaneous demand from patients or foster more engagement in their medication management. The variable settings illustrated the diversity of medication management and the need for local adaptations.

Conclusions

The results of our study present a unique and comprehensive description of the sociotechnical challenges of implementing shared electronic medication plans in primary care. The shared ownership among multiple stakeholders is a core challenge for implementers. No single stakeholder can build and maintain a safe, usable HIT system with up-to-date medication information. Buy-in from all involved health care professionals is necessary for consistent medication reconciliation along the entire care pathway. Implementers must balance the need to change clinical processes to achieve improvements with the need to integrate the shared electronic medication plan into existing routines to facilitate adoption. The lack of patient involvement warrants further study.

Weighing the odds: Assessing underdiagnosis of adult obesity via electronic medical record problem list omissions

Background

Obesity is a continuing national epidemic, and the condition can have a physical, psychological, as well as social impact on one’s well-being. Consequently, it is critical to diagnose and document obesity accurately in the patient’s electronic medical record (EMR), so that the information can be used and shared to improve clinical decision making and health communication and, in turn, the patient’s prognosis. It is therefore worthwhile identifying the various factors that play a role in documenting obesity diagnosis and the methods to improve current documentation practices.

Method

We used a retrospective cross-sectional design to analyze outpatient EMRs of patients at an academic outpatient clinic. Obese patients were identified using the measured body mass index (BMI; ≥30 kg/m²) entry in the EMR, recorded at each visit, and checked for documentation of obesity in the EMR problem list. Patients were categorized into two groups (diagnosed or undiagnosed) based on a documented diagnosis (or omission) of obesity in the EMR problem list and compared.

Results

A total of 10,208 unique patient records of obese patients were included for analysis, of which 4119 (40%) did not have any documentation of obesity in their problem list. Chi-square analysis between the diagnosed and undiagnosed groups revealed significant associations between documentation of obesity in the EMR and patient characteristics.

Conclusion

EMR designers and developers must consider employing automated decision support techniques to populate and update problem lists based on the existing recorded BMI in the EMR in order to prevent omissions occurring from manual entry.

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.

Unexpected Increase in Benzodiazepine Prescriptions Related to the Introduction of an Electronic Prescribing Tool: Evidence from Multicenter Hospital Data

Electronic Prescribing tools (e-prescribing) have shown several benefits in terms of prescribing process adequacy and health care quality in hospital settings. We hypothesize however, that an undesired effect of digitalisation, due to the easier and faster prescribing process allowing patients to skip face-to-face conversations with patients and nurses, is that it could facilitate the prescription of medications at high risk of overuse or abuse, such as benzodiazepines (BZDs). We conducted a panel data study to investigate, the impact of the introduction of an e-prescribing system on new BZD prescriptions in hospitalised patients in a network of five teaching hospitals. During the observation period 1 July 2014-30 April 2019, 43,320 admissions were analysed. A fixed-effects model was adopted to estimate the effect of e-prescribing on new BZD prescriptions. E-prescribing implementation was associated with a significant increase of new BZD prescriptions: absolute +1.5%, and relative +43% (p < 0.001). The effect was similar in males and females (respectively, absolute +2.3%, relative +65% (p < 0.001); absolute +1.8%, relative +58% (p = 0.01)) and in patients ≥70 years old (absolute +1.6%, relative +59% (p < 0.001)). After controlling for time-varying explanatory variables, the implementation of the e-prescribing tool showed similar significant effects. E-prescribing implementation was associated with a significant increase of new in-hospital BZD prescriptions. For classes of drugs at risk of overuse or abuse, e-prescribing should be used cautiously, to minimize the risk of over-prescriptions. Further research in other settings and countries is needed to analyse causal interactions between e-prescribing and BZD prescriptions in the hospital setting, and to promote the ultimate goal of high-value care.

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.

Online Health Technologies and Mobile Devices: Attitudes, Needs, and Future

Advances in mobile technology constitute a promising and evolving trend that enables better access to health care especially for the elderly, disabled, and chronically ill. It overcomes geographical, temporal, and organizational barriers at low and affordable costs. The aim of the study was to evaluate the needs and expectations of Polish citizens and their attitudes toward mobile health (mHealth) services using mobile phones and communication devices in medical care and also to evaluate the sociodemographic factors affecting such behavioral processes. A total of 1000 adults were selected from the Polish population by random sampling. The assessment was made with the use of computer-assisted telephone interview (CATI). Approximately 78% of the study participants were proficient mobile phone users with a predominance of young people. Forty-seven percent of them expressed the desire to obtain information about their health via their mobile phone if they had the opportunity to do so. Important factors associated with the aforementioned statement included younger age, being still in education, or unemployed. Among the mHealth supporters, the vast majority of people (84%) would like to receive SMS (short message service) reminders for appointments and prescribed medicines. Other favorable mHealth activities were e-registration (77.9%), viewing test results online (80.6%), or receiving basic medical recommendations (75.7%). Only 30% of the respondents had a positive attitude toward teleconsultation, while 17.8% of them were willing to pay for this option. Further research on emerging new and beneficial mHealth solutions needs to be conducted.

A method for harmonization of clinical abbreviation and acronym sense inventories

BACKGROUND

Previous research has developed methods to construct acronym sense inventories from a single institutional corpus. Although beneficial, a sense inventory constructed from a single institutional corpus is not generalizable, because acronyms from different geographic regions and medical specialties vary greatly.

OBJECTIVE

Develop an automated method to harmonize sense inventories from different regions and specialties towards the development of a comprehensive inventory.

METHODS

The method involves integrating multiple source sense inventories into one centralized inventory and cross-mapping redundant entries to establish synonymy. To evaluate our method, we integrated 8 well-known source inventories into one comprehensive inventory (or metathesaurus). For both the metathesaurus and its sources, we evaluated the coverage of acronyms and their senses on a corpus of 1 million clinical notes. The corpus came from a different institution, region, and specialty than the source inventories.

RESULTS

In the evaluation using clinical notes, the metathesaurus demonstrated an acronym (short form) micro-coverage of 94.3%, representing a substantial increase over the two next largest source inventories, the UMLS LRABR (74.8%) and ADAM (68.0%). The metathesaurus demonstrated a sense (long form) micro-coverage of 99.6%, again a substantial increase compared to the UMLS LRABR (82.5%) and ADAM (55.4%).

CONCLUSIONS

Given the high coverage, harmonizing acronym sense inventories is a promising methodology to improve their comprehensiveness. Our method is automated, leverages the extensive resources already devoted to developing institution-specific inventories in the United States, and may help generalize sense inventories to institutions who lack the resources to develop them. Future work should address quality issues in source inventories and explore additional approaches to establishing synonymy.

Engaging hospital patients in the medication reconciliation process using tablet computers

Objective

Unintentional medication discrepancies contribute to preventable adverse drug events in patients. Patient engagement in medication safety beyond verbal participation in medication reconciliation is limited. We conducted a pilot study to determine whether patients' use of an electronic home medication review tool could improve medication safety during hospitalization.

Materials and Methods

Patients were randomized to use a tool before or after hospital admission medication reconciliation to review and modify their home medication list. We assessed the quantity, potential severity, and potential harm of patients' and clinicians' medication changes. We also surveyed clinicians to assess the tool's usefulness.

Results

Of 76 patients approached, 65 (86%) participated. Forty-eight (74%) made changes to their home medication list [before: 29 (81%), after: 19 (66%), p = .170]. Before group participants identified 57 changes that clinicians subsequently missed on admission medication reconciliation. Thirty-nine (74%) had a significant or greater potential severity, and 19 (36%) had a greater than 50-50 chance of harm. After group patients identified 68 additional changes to their reconciled medication lists. Fifty-one (75%) had a significant or greater potential severity, and 33 (49%) had a greater than 50-50 chance of harm. Clinicians reported believing that the tool would save time, and patients would supply useful information.

Discussion

The results demonstrate a high willingness of patients to engage in medication reconciliation, and show that patients were able to identify important medication discrepancies and often changes that clinicians missed.

Conclusion

Engaging patients in admission medication reconciliation using an electronic home medication review tool may improve medication safety during hospitalization.

Evaluation of Patient and Family Engagement Strategies to Improve Medication Safety

BACKGROUND

Patient and family engagement (PFE) is critical for patient safety. We systematically reviewed types of PFE strategies implemented and their impact on medication safety.

METHODS

We searched MEDLINE, EMBASE, reference lists and websites to August 2016. Two investigators independently reviewed all abstracts and articles, and articles were additionally reviewed by two senior investigators for selection. One investigator abstracted data and two investigators reviewed the data for accuracy. Study quality was determined by consensus. Investigators developed a framework for defining the level of patient engagement: informing patients about medications (Level 1), informing about engagement with health care providers (Level 2), empowering patients with communication tools and skills (Level 3), partnering with patients in their care (Level 4), and integrating patients as full care team members (Level 5).

RESULTS

We included 19 studies that mostly targeted older adults taking multiple medications. The median level of engagement was 2, ranging from 2-4. We identified no level 5 studies. Key themes for patient engagement strategies impacting medication safety were patient education and medication reconciliation, with a subtheme of patient portals. Most studies (84%) reported implementation outcomes. The most commonly reported medication safety outcomes were medication errors, including near misses and discrepancies (47%), and medication safety knowledge (37%). Most studies (63%) were of medium to low quality, and risk of bias was generally moderate. Among the 11 studies with control groups, 55% (n = 6) reported statistically significant improvement on at least one medication safety outcome. Further synthesis of medication safety measures was limited due to intervention and outcome heterogeneity.

CONCLUSIONS

Key strategies for engaging patients in medication safety are education and medication reconciliation. Patient engagement levels were generally low, as defined by a novel framework for determining levels of patient engagement. As more patient engagement studies are conducted, this framework should be evaluated for associations with patient outcomes.

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.

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.

Challenges with Collecting Smoking Status in Electronic Health Records

Smoking is the leading cause of preventable death in the United States. Obtaining patients' smoking status is the first step in delivering smoking cessation counseling. In this study, we assessed the quality of smoking status captured in an electronic health record from a large academic medical center. We analyzed data from structured notes, finding that smoking status was documented in 98% of 64,451 hospital encounters in 2016. 32% hospital encounters had discrepant documentation, and 54.5% of patients had implausible changes (e.g., changes from "current smoker" to "never smoker"). Overall, only 2.9% of patients were documented as active smokers, but 36.4% were documented as "unknown" or had discrepancies in their smoking status. These results suggest that patients that smoke are not appropriately identified. Centralized documentation with clinically actionable smoking status categories and implementation of patient-facing tools that allow patients to directly record their information could improve data quality of smoking status.

Patient Health Record Systems Scope and Functionalities: Literature Review and Future Directions

BACKGROUND

A new generation of user-centric information systems is emerging in health care as patient health record (PHR) systems. These systems create a platform supporting the new vision of health services that empowers patients and enables patient-provider communication, with the goal of improving health outcomes and reducing costs. This evolution has generated new sets of data and capabilities, providing opportunities and challenges at the user, system, and industry levels.

OBJECTIVE

The objective of our study was to assess PHR data types and functionalities through a review of the literature to inform the health care informatics community, and to provide recommendations for PHR design, research, and practice.

METHODS

We conducted a review of the literature to assess PHR data types and functionalities. We searched PubMed, Embase, and MEDLINE databases from 1966 to 2015 for studies of PHRs, resulting in 1822 articles, from which we selected a total of 106 articles for a detailed review of PHR data content.

RESULTS

We present several key findings related to the scope and functionalities in PHR systems. We also present a functional taxonomy and chronological analysis of PHR data types and functionalities, to improve understanding and provide insights for future directions. Functional taxonomy analysis of the extracted data revealed the presence of new PHR data sources such as tracking devices and data types such as time-series data. Chronological data analysis showed an evolution of PHR system functionalities over time, from simple data access to data modification and, more recently, automated assessment, prediction, and recommendation.

CONCLUSIONS

Efforts are needed to improve (1) PHR data quality through patient-centered user interface design and standardized patient-generated data guidelines, (2) data integrity through consolidation of various types and sources, (3) PHR functionality through application of new data analytics methods, and (4) metrics to evaluate clinical outcomes associated with automated PHR system use, and costs associated with PHR data storage and analytics.

Transitions from biomedical to recovery-oriented practices in mental health: a scoping review to explore the role of Internet-based interventions

Background

The Internet is transforming mental health care services by increasing access to, and potentially improving the quality of, care. Internet-based interventions in mental health can potentially play a role in transitions from biomedical to recovery-oriented research and practices, but an overview of what this may entail, current work, and issues that need addressing, is lacking. The objective of this study is to describe Internet-based recovery-oriented interventions (referred to as e-recovery) and current research, and to identify gaps and issues relevant to advancing recovery research and practices through opportunities provided by the Internet.

Methods

Five iterative stages of a scoping review framework were followed in searching and analyzing the literature. A recovery framework with four domains and 16 themes was used to deductively code intervention characteristics according to their support for recovery-oriented practices. Only Internet-based interventions used in conjunction with ongoing care were included.

Results

Twenty studies describing six e-recovery interventions were identified and originated in Australia, Finland, the Netherlands, Norway and USA. The domain supporting personal recovery was most clearly reflected in interventions, whereas the last three domains, i.e., promoting citizenship, organizational commitment and working relationship were less evident. Support for the formulation and follow-up of personal goals and preferences, and in accessing peer-support, were the characteristics shared by most interventions. Three of the six studies that employed a comparison group used randomization, and none presented definitive findings. None used recovery-oriented frameworks or specific recovery outcome measures. Four of the interventions were specific to a diagnosis.

Conclusion

Research about how technologies might aid in illuminating and shaping recovery processes is in its formative stages. We recommend that future e-recovery research and innovation attend to four dimensions: evidence-supported interventions, new knowledge about personal recovery, values-based approaches and Internet as a facilitator for organizational transformation. The incremental changes facilitated by e-recovery may help propel a shift in mental health care toward recovery-oriented practices.

When doctors share visit notes with patients: a study of patient and doctor perceptions of documentation errors, safety opportunities and the patient-doctor relationship

BACKGROUND

Patient advocates and safety experts encourage adoption of transparent health records, but sceptics worry that shared notes may offend patients, erode trust or promote defensive medicine. As electronic health records disseminate, such disparate views fuel policy debates about risks and benefits of sharing visit notes with patients through portals.

METHODS

Presurveys and postsurveys from 99 volunteer doctors at three US sites who participated in OpenNotes and postsurveys from 4592 patients who read at least one note and submitted a survey.

RESULTS

Patients read notes to be better informed and because they were curious; about a third read them to check accuracy. In total, 7% (331) of patients reported contacting their doctor's office about their note. Of these, 29% perceived an error, and 85% were satisfied with its resolution. Nearly all patients reported feeling better (37%) or the same (62%) about their doctor. Patients who were older (>63), male, non-white, had fair/poor self-reported health or had less formal education were more likely to report feeling better about their doctor. Among doctors, 26% anticipated documentation errors, and 44% thought patients would disagree with notes. After a year, 53% believed patient satisfaction increased, and 51% thought patients trusted them more. None reported ordering more tests or referrals.

CONCLUSIONS

Despite concerns about errors, offending language or defensive practice, transparent notes overall did not harm the patient-doctor relationship. Rather, doctors and patients perceived relational benefits. Traditionally more vulnerable populations-non-white, those with poorer self-reported health and those with fewer years of formal education-may be particularly likely to feel better about their doctor after reading their notes. Further informing debate about OpenNotes, the findings suggest transparent records may improve patient satisfaction, trust and safety.

Integrating patient voices into health information for self-care and patient-clinician partnerships: Veterans Affairs design recommendations for patient-generated data applications

Electronic health record content is created by clinicians and is driven largely by intermittent and brief encounters with patients. Collecting data directly from patients in the form of patient-generated data (PGD) provides an unprecedented opportunity to capture personal, contextual patient information that can supplement clinical data and enhance patients' self-care. The US Department of Veterans Affairs (VA) is striving to implement the enterprise-wide capability to collect and use PGD in order to partner with patients in their care, improve the patient healthcare experience, and promote shared decision making. Through knowledge gained from Veterans' and healthcare teams' perspectives, VA created a taxonomy and an evolving framework on which to design and develop applications that capture and help physicians utilize PGD. Ten recommendations for effectively collecting and integrating PGD into patient care are discussed, addressing health system culture, data value, architecture, policy, data standards, clinical workflow, data visualization, and analytics and population reach.

Interactive tools for inpatient medication tracking: a multi-phase study with cardiothoracic surgery patients

OBJECTIVE

Prior studies of computing applications that support patients' medication knowledge and self-management offer valuable insights into effective application design, but do not address inpatient settings. This study is the first to explore the design and usefulness of patient-facing tools supporting inpatient medication management and tracking.

MATERIALS AND METHODS

We designed myNYP Inpatient, a custom personal health record application, through an iterative, user-centered approach. Medication-tracking tools in myNYP Inpatient include interactive views of home and hospital medication data and features for commenting on these data. In a two-phase pilot study, patients used the tools during cardiothoracic postoperative care at Columbia University Medical Center. In Phase One, we provided 20 patients with the application for 24-48 h and conducted a closing interview after this period. In Phase Two, we conducted semi-structured interviews with 12 patients and 5 clinical pharmacists who evaluated refinements to the tools based on the feedback received during Phase One.

RESULTS

Patients reported that the medication-tracking tools were useful. During Phase One, 14 of the 20 participants used the tools actively, to review medication lists and log comments and questions about their medications. Patients' interview responses and audit logs revealed that they made frequent use of the hospital medications feature and found electronic reporting of questions and comments useful. We also uncovered important considerations for subsequent design of such tools. In Phase Two, the patients and pharmacists participating in the study confirmed the usability and usefulness of the refined tools.

CONCLUSIONS

Inpatient medication-tracking tools, when designed to meet patients' needs, can play an important role in fostering patient participation in their own care and patient-provider communication during a hospital stay.

Consumer Engagement in Health IT: Distinguishing Rhetoric from Reality

RATIONALE

Policymakers want health information technology (health IT) to support consumer engagement to help achieve national health goals. In this paper, we review the evidence to compare the rhetoric with the reality of current practice.

CURRENT REALITY AND BARRIERS

Our environmental scan shows that consumer demand exists for electronic access to personal health information, but that technical and system or political barriers still limit the value of the available information and its potential benefits.

CONCLUSIONS AND POLICY IMPLICATIONS

There is a gap between current reality and the goals for consumer engagement. Actions that may help bridge this gap include: (1) resolving technical barriers to health information exchange (HIE); (2) developing more consumer-centric design and functionality; (3) reinforcing incentives that attract provider support by showing that consumer engagement is in their interest; and (4) building a stronger empirical case to convince decision makers that consumer engagement will lead to better care, improved health outcomes, and lower costs.

IT-enabled Community Health Interventions: Challenges, Opportunities, and Future Directions

Rising health information technology (HIT) adoption and the increasing interoperability of health data have propelled the role of IT in community-wide health transformations. Disseminating the challenges and opportunities that the early adopters of community-wide HIT interventions have experienced is critical for empowering the growing demand for community-based health systems. This special issue of eGEMs addresses that need. This issue includes a variety of community-based HIT projects covering topics such as governance, informatics, and learning health systems. These projects represent a diverse set of stakeholders, a wide selection of data sources, and multiple information platforms to collate or exchange data. We hope that this special issue of eGEMs will be the first of several future issues dedicated to community-wide HIT transformations.