Physician and Pharmacist Medication Decision-Making in the Time of Electronic Health Records: Mixed-Methods Study

Co-designing resources for rehabilitation via telehealth for people with moderate to severe disability post stroke

OBJECTIVES

The COVID-19 pandemic necessitated rapid transition to telehealth. Telehealth presents challenges for rehabilitation of stroke survivors with moderate-to-severe physical disability, which traditionally relies on physical interactions. The objective was to co-design resources to support delivery of rehabilitation via telehealth for this cohort.

DESIGN

Four-stage integrated knowledge translation co-design approach. Stage 1: Research team comprising researchers, clinicians and stroke survivors defined the research question and approach. Stage 2: Workshops and interviews were conducted with knowledge users (participants) to identify essential elements of the program. Stage 3: Resources developed by the research team. Stage 4: Resources reviewed by knowledge users and adapted.

PARTICIPANTS

Twenty-one knowledge users (clinicians n = 11, stroke survivors n = 7, caregivers n = 3) RESULTS: All stakeholders emphasised the complexities of telehealth rehabilitation for stroke and the need for individualised programs. Shared decision-making was identified as critical. Potential risks and benefits of telehealth were acknowledged and strategies to ameliorate risks and deliver effective rehabilitation were identified. Four freely available online resources were co-designed; three resources to support clinicians with shared decision-making and risk management and a decision-aid to support stroke survivors and caregivers throughout the process. Over six months, 1129 users have viewed the webpage; clinician resources were downloaded 374 times and the decision-aid was downloaded 570 times.

CONCLUSIONS

The co-design process identified key elements for delivery of telehealth rehabilitation to stroke survivors with moderate-to-severe physical disability and led to development of resources to support development of an individualised telehealth rehabilitation plan. Future research should evaluate the effectiveness of these resources. CONTRIBUTION OF PAPER.

Factors identified as barriers or facilitators to EMR/EHR based interprofessional primary care: a scoping review

As interprofessional collaboration (IPC) in primary care receives increasing attention, the role of electronic medical and health record (EMR/EHR) systems in supporting IPC is important to consider. A scoping review was conducted to synthesize the current literature on the barriers and facilitators of EMR/EHRs to interprofessional primary care. Four online databases (OVID Medline, EBSCO CINAHL, OVID EMBASE, and OVID PsycINFO) were searched without date restrictions. Twelve studies were included in the review. Of six facilitator and barrier themes identified, the key facilitator was teamwork support and a significant barrier was data management. Other important barriers included usability related mainly to interoperability, and practice support primarily in terms of patient care. Additional themes were organization attributes and user features. Although EMR/EHR systems facilitated teamwork support, there is potential for team features to be strengthened further. Persistent barriers may be partly addressed by advances in software design, particularly if interprofessional perspectives are included. Organizations and teams might also consider strategies for working with existing EMR/EHR systems, for instance by developing guidelines for interprofessional use. Further research concerning the use of electronic records in interprofessional contexts is needed to support IPC in primary care.

Collaborative medication reviews in community pharmacies-Drug-related problems and the process of communicating them with physicians: A retrospective validation study

Background and Aims

Cooperation between practicing community pharmacists (PPs) and primary care physicians has traditionally been limited, with scarce communication on therapeutic issues. The aim of this study was to assess how PPs communicate in writing with physicians regarding (1) the clinically relevant problems they have identified in patients' medications and (2) recommendations to solve the problems to identify development needs in the communication process.

Methods

This retrospective validation study assessed medication reviews conducted by PPs in collaboration with home care nurses, practice nurses, and physicians for 46 older (≥65 years) home care clients in the Municipality of Lohja, Finland. The therapeutic and communicative appropriateness of clinically relevant drug-related problems (DRPs) identified by PPs and reported in writing to physicians was blindly evaluated by (1) an accredited pharmacist (AP) and (2) two physicians specialized in geriatric pharmacotherapy. Descriptive statistical analysis was conducted to compare the assessments.

Results

The PPs (n = 13) identified 189 DRPs and made 4.1 recommendations per patient in 46 written reports to physicians. Of the PPs' written recommendations for medication changes, 46% (155/334) were the same as those by the AP. The two specialized physicians evaluated 69% and 67% of PPs' recommendations to be clinically relevant. The way the DRPs and recommendations to solve them were communicated was evaluated as appropriate in 38% and 38%, respectively, of the case reports written by the PPs.

Conclusion

The PPs were able identify DRPs quite well, particularly inappropriate medication use, according to current care guidelines and formularies. It was found that improvement was needed in the communication of DRPs in written reports with physicians. Interprofessional learning by working in care teams would be suitable for strengthening patient care-oriented competencies.

Exploring medication safety structures and processes in nursing homes: a cross-sectional study

BACKGROUND

Medication safety is important to limit adverse events for nursing home residents. Several factors, such as interprofessional collaboration with pharmacists and medication reviews, have been shown in the literature to influence medication safety processes.

AIM

This study had three main objectives: (1) To assess how facility- and unit-level organization and infrastructure are related to medication use processes; (2) To determine the extent of medication safety-relevant processes; and (3) To explore pharmacies' and pharmacists' involvement in nursing homes' medication-related processes.

METHOD

Cross-sectional multicenter survey data (2018-2019) from a convenience sample of 118 Swiss nursing homes were used. Data were collected on facility and unit characteristics, pharmacy services, as well as medication safety-related structures and processes. Descriptive statistics were used.

RESULTS

Most of the participating nursing homes (93.2%) had electronic resident health record systems that supported medication safety in various ways (e.g., medication lists, interaction checks). Electronic data exchanges with outside partners such as pharmacies or physicians were available for fewer than half (10.2-46.3%, depending on the partner). Pharmacists collaborating with nursing homes were mainly involved in logistical support. Medication reviews were reportedly conducted regularly in two-thirds of facilities.

CONCLUSION

A high proportion of Swiss nursing homes have implemented diverse processes and structures that support medication use and safety for residents; however, their collaboration with pharmacists remains relatively limited.

Shared decision-making practices and patient values in pharmacist outpatient care for rheumatic disease: A multiple correspondence analysis

Purpose: To investigate the value-to-value relationships, relationship between values and patient background, continuation rate of treatment after shared decision-making (SDM), and disease status in order to clarify the values involved in drug therapy decisions for patients with rheumatic disease. Methods: We investigated patient values (efficacy of drug therapy [effectiveness], safety, economics, daily life, and other) and the continuance rate and disease status of treatment after 6 months in 94 patients with rheumatic disease aged ≥18 years who made decisions with pharmacists and physicians in the pharmacy outpatient clinic between September 2019 and April 2021. Multiple correspondence and K-means cluster analyses were performed to show the relationship between values and basic patient information. Results: Among the selected patients, 87% and 47% selected effectiveness for multiple selections and single selection, respectively. Effectiveness was at the center of the graph; three clusters containing other values were placed around it. History of allergy or side effects caused by biologics or Janus kinase inhibitors were in the safety cluster. The non-usage history of biologics or Janus kinase inhibitors was in the economic cluster. Conclusion: Effectiveness was the most important factor for patients with rheumatic disease; the values that patients consider important may shift from effectiveness to other values based on each patient's subjective experience with the treatment and/or the stage of life in which they were treated. It is important to positively link patient values and information about the treatment plan in shared decision-making while establishing rapport with the patient.

The impact of clinical pharmacist-physician communication on reducing drug-related problems: a mixed study design in a tertiary teaching Hospital in Xinjiang, China

BACKGROUND

The incidence of drug-related problems (DRPs) has caused serious health hazards and economic burdens among polymedicine patients. Effective communication between clinical pharmacists and physicians has a significant impact on reducing DRPs, but the evidence is poor. This study aimed to explore the impact of communication between clinical pharmacists and physicians on reducing DRPs.

METHODS

A semistructured interview was conducted to explore the communication mode between clinical pharmacists and physicians based on the interprofessional approach of the shared decision-making model and relational coordination theory. A randomized controlled trial (RCT) was used to explore the effects of communication intervention on reducing DRPs. Logistic regression analysis was used to identify the influencing factors of communication.

RESULTS

The mode of communication is driven by clinical pharmacists between clinical pharmacists and physicians and selectively based on different DRP types. Normally, the communication contents only cover two (33.8%) types of DRP contents or fewer (35.1%). The communication time averaged 5.8 minutes. The communication way is predominantly face-to-face (91.3%), but telephone or other online means (such as WeChat) may be preferred for urgent tasks or long physical distances. Among the 367 participants, 44 patients had DRPs. The RCT results indicated a significant difference in DRP incidence between the control group and the intervention group after the communication intervention (p = 0.02), and the incidence of DRPs in the intervention group was significantly reduced (15.6% vs. 0.07%). Regression analysis showed that communication time had a negative impact on DRP incidence (OR = 13.22, p < 0.001).

CONCLUSION

The communication mode based on the interprofessional approach of the shared decision-making between clinical pharmacists and physicians in medication decision-making could significantly reduce the incidence of DRPs, and the length of communication time is a significant factor. The longer the communication time is, the fewer DRPs that occur.

TRIAL REGISTRATION

This trial was approved by the ethics committee of The First Affiliated Hospital of Medical College of Xinjiang Shihezi University Hospital (kj2020-087-03) and registered in the China clinical trial registry (https://www.chictr.org.cn , number ChiCTR2000035321 date: 08/08/2020).

Systematic literature review of pharmacists in general practice in supporting the implementation of shared care agreements in primary care

BACKGROUND

Rising demand for healthcare continues to impact all sectors of the health service. As a result of the growing ageing population and the burden of chronic disease, healthcare has become more complex, and the need for more efficient management of specialist medication across the healthcare interface is of paramount importance. With the rising number of pharmacists working in primary care in clinical roles, is this a role that pharmacists could support to ensure the successful execution of shared care agreement (SCA) in primary care for these patients?

AIM OF THE REVIEW

Systematic review to identify activities and assess the interventions provided by pharmacists in primary care on SCA provision and how it affects health-related quality of life (HRQoL) for patients.

METHOD

Primary studies in English which tested the intervention or obtained views of stakeholders related to pharmacist input to shared care agreement within primary care were included. The following electronic databases were systematically searched from the date of inception to November 2021: AMED®, CINAHL®, Cochrane Database of Systematic Reviews (CDSR), EMBASE®, EMCARE®, Google Scholar, HMIC®, MEDLINE®, PsycINFO®, Scopus and Web of Science®. Grey literature sources were also searched. The search was adapted according to the respective database-specific search tools. It was searched using a combination of Medical Subject Heading terms (MeSH), free-text search terms and Boolean operators.

RESULTS

A total of 5244 titles/abstracts were screened after duplicates were removed, and 64 full articles were assessed for eligibility. On examination of full text, no studies met the inclusion criteria for this review.

CONCLUSION

This review highlights the need for further research to evaluate how pharmacists in general practice can support the safe and effective integration of specialist medication in primary care with the use of SCA.

SYSTEMATIC REVIEW REGISTRATION

NIHR PROSPERO No: 2020 CRD42020165363 .

Exploring the Experiences of Family Caregivers of Children With Special Health Care Needs to Inform the Design of Digital Health Systems: Formative Qualitative Study

BACKGROUND

Family caregivers of children with special health care needs (CSHCN) are responsible for managing and communicating information regarding their child's health in their homes. Although family caregivers currently capture information through nondigital methods, digital health care applications are a promising solution for supporting the standardization of information management in complex home care across their child's health care team. However, family caregivers continue to use paper-based methods where the adoption of digital health care tools is low. With the rise in home care for children with complex health care needs, it is important to understand the caregiving work domain to inform the design of technologies that support child safety in the home.

OBJECTIVE

The aim of this study is to explore how family caregivers navigate information management and communication in complex home care for CSHCN.

METHODS

This research is part of a broader study to explore caregivers' perspectives on integrating and designing digital health care tools for complex home care. The broader study included interviews and surveys about designing a voice user interface to support home care. This formative study explored semistructured interview data with family caregivers of CSHCN about their home care situations. Inductive thematic analysis was used to analyze the information management and communication processes.

RESULTS

We collected data from 7 family caregivers in North America and identified 5 themes. First, family caregivers were continuously learning to provide care. They were also updating the caregiver team on their child's status and teaching caregivers about their care situation. As caregiving teams grew, they found themselves working on communicating with their children's educators. Beyond the scope of managing their child's health information, family caregivers also navigated bureaucratic processes for their child's home care.

CONCLUSIONS

Family caregivers' experiences of caring for CSHCN differ contextually and evolve as their child's condition changes and they grow toward adulthood. Family caregivers recorded information using paper-based tools, which did not sufficiently support information management. They also experienced significant pressure in summarizing information and coordinating 2-way communication about the details of their child's health with caregivers. The design of digital health care systems and tools for complex home care may improve care coordination if they provide an intuitive method for information interaction and significant utility by delivering situation-specific insights and adapting to unique and dynamic home care environments. Although these findings provide a foundational understanding, there is an opportunity for further research to generalize the findings.

Including the Reason for Use on Prescriptions Sent to Pharmacists: Scoping Review

BACKGROUND

In North America, although pharmacists are obligated to ensure prescribed medications are appropriate, information about a patient's reason for use is not a required component of a legal prescription. The benefits of prescribers including the reason for use on prescriptions is evident in the current literature. However, it is not standard practice to share this information with pharmacists.

OBJECTIVE

Our aim was to characterize the research on how including the reason for use on a prescription impacts pharmacists.

METHODS

We performed an interdisciplinary scoping review, searching literature in the fields of health care, informatics, and engineering. The following databases were searched between December 2018 and January 2019: PubMed, Institute of Electrical and Electronics Engineers (IEEE), Association for Computing Machinery (ACM), International Pharmaceutical Abstracts (IPA), and EMBASE.

RESULTS

A total of 3912 potentially relevant articles were identified, with 9 papers meeting the inclusion criteria. The studies used different terminology (eg, indication, reason for use) and a wide variety of study methodologies, including prospective and retrospective observational studies, randomized controlled trials, and qualitative interviews and focus groups. The results suggest that including the reason for use on a prescription can help the pharmacist catch more errors, reduce the need to contact prescribers, support patient counseling, impact communication, and improve patient safety. Reasons that may prevent prescribers from adding the reason for use information are concerns about workflow and patient privacy.

CONCLUSIONS

More research is needed to understand how the reason for use information should be provided to pharmacists. In the limited literature to date, there is a consensus that the addition of this information to prescriptions benefits patient safety and enables pharmacists to be more effective. Future research should use an implementation science or theory-based approach to improve prescriber buy-in and, consequently, adoption.

Perspectives of pharmacists about collaborative asthma care model in primary care

BACKGROUND

The newly recognized General Practice Pharmacist (GPP) model in Australia, where non-dispensing pharmacists work in collaboration with general practitioners (primary care physicians) within their general practice/clinics represent an efficient yet novel approach for the management of chronic diseases. In chronic conditions, such as asthma, these models can help achieve optimal health outcomes, given current gaps between guidelines and practice.

OBJECTIVE

The aim of this study was to elicit pharmacists' views and recommendations about pragmatic models of collaboration between GPPs and general practitioners in providing asthma management services in future service delivery models.

METHODS

Community pharmacists were recruited via convenience sampling and passive snowballing techniques. Qualitative, semi-structured, in-depth interviews were conducted. Recorded interviews were transcribed verbatim and analyzed utilizing NVivo® 11 software. Obtained data were content analyzed for emergent themes using the Braun and Clarke framework.

RESULTS

Twenty-five interviews were conducted. Asthma management challenges in current practice and the implementation practicality of asthma care GPP models comprised the two major emerging themes. Pharmacists' time and workload constraints and patients' reluctance to seek pharmacists' assistance to dispel misconceptions about asthma control were reported to be major barriers for the implementation of optimal asthma management services in community pharmacy. While a GPP dependent on several criteria. The development of specified channels for inter-professional communication for sharing of patient information and the willingness of stakeholders to accept and access such a model were reported. Funding and remuneration were considered critical factors by most participants. The professional self-autonomy of each healthcare professional involved in the GPP model was also highlighted as pertinent issue.

CONCLUSIONS

This study provides significant insights to create pragmatic scalable versions of a GPP care model that could facilitate better asthma care after key barriers and facilitators identified by participants are carefully addressed.

Community pharmacists' and residents' decision making and unmet information needs when completing comprehensive medication reviews

OBJECTIVE

To (1) characterize community pharmacists' and community pharmacy residents' decision making and unmet information needs when conducting comprehensive medication reviews (CMRs) as part of medication therapy management and (2) explore any differences between community pharmacists and community pharmacy residents in CMR decision making and unmet information needs.

DESIGN

Thirty-to 60-minute semistructured interviews framed using a clinical decision-making model (CDMM) were conducted with community pharmacists and residents.

SETTING AND PARTICIPANTS

Participants were recruited from practice-based research networks and researchers' professional networks. Eligible participants had completed or supported the completion of at least 2 CMRs in the last 30 days.

OUTCOME MEASURES

Two researchers independently coded transcripts using a combination of inductive and deductive methods to identify themes pertaining to community pharmacists' and residents' decision making and unmet information needs in the provision of CMRs. Discrepancies among researchers' initial coding decisions were resolved through discussion.

RESULTS

Sixteen participants (8 pharmacists and 8 residents) were interviewed. Themes were mapped to 5 CDMM steps. Participants primarily used subjective information during "case familiarization"; objective information was secondary. Information used for "generating initial hypotheses" varied by medication therapy problem (MTP) type. During "case assessment," if information was not readily available, participants sought information from patients. Thus, patients' levels of self-management and health literacy influenced participants' ability to identify and resolve MTPs, as described under "identifying final hypotheses." Finally, participants described "decision-making barriers," including communication with prescribers to resolve MTPs. Although pharmacist and resident participants varied in the types of MTPs identified, both groups cited the use and need of similar information.

CONCLUSION

Community pharmacists and residents often rely primarily on patient-provided information for decision making during CMRs because of unmet information needs, specifically, objective information. Moreover, confidence in MTP identification and resolution is reduced by communication challenges with prescribers and limitations in patients' ability to convey accurate and necessary information.

Understanding the Situated Roles of Electronic Medical Record Systems to Enable Redesign: Mixed Methods Study

BACKGROUND

Redesigning electronic medical record (EMR) systems is needed to improve their usability and usefulness. Similar to other artifacts, EMR systems can evolve with time and exhibit situated roles. Situated roles refer to the ways in which a system is appropriated by its users, that is, the unintended ways the users engage with, relate to, and perceive the system in its context of use. These situated roles are usually unknown to the designers as they emerge and evolve as a response by the users to a contextual need or constraint. Understanding the system's situated roles can expose the unarticulated needs of the users and enable redesign opportunities.

OBJECTIVE

This study aimed to find EMR redesign opportunities by understanding the situated roles of EMR systems in prenatal care settings.

METHODS

We conducted a field-based observational study at a Japanese prenatal care clinic. We observed 3 obstetricians and 6 midwives providing prenatal care to 37 pregnant women. We looked at how the EMR system is used during the checkups. We analyzed the observational data following a thematic analysis approach and identified the situated roles of the EMR system. Finally, we administered a survey to 5 obstetricians and 10 midwives to validate our results and understand the attitudes of the prenatal care staff regarding the situated roles of the EMR system.

RESULTS

We identified 10 distinct situated roles that EMR systems play in prenatal care settings. Among them, 4 roles were regarded as favorable as most users wanted to experience them more frequently, and 4 roles were regarded as unfavorable as most users wanted to experience them less frequently; 2 ambivalent roles highlighted the providers' reluctance to document sensitive psychosocial information in the EMR and their use of the EMR system as an accomplice to pause communication during the checkups. To improve the usability and usefulness of EMR systems, designers can amplify the favorable roles and minimize the unfavorable roles. Our results also showed that obstetricians and midwives may have different experiences, wants, and priorities regarding the use of the EMR system.

CONCLUSIONS

Currently, EMR systems are mainly viewed as tools that support the clinical workflow. Redesigning EMR systems is needed to amplify their roles as communication support tools. Our results provided multiple EMR redesign opportunities to improve the usability and usefulness of EMR systems in prenatal care. Designers can use the results to guide their EMR redesign activities and align them with the users' wants and priorities. The biggest challenge is to redesign EMR systems in a way that amplifies their favorable roles for all the stakeholders concurrently.

"My pharmacist": Creating and maintaining relationship between physicians and pharmacists in primary care settings

BACKGROUND

Pharmacists and physicians are being increasingly encouraged to adopt a collaborative approach to patient care, and delivery of health services. Strong collaboration between pharmacists and physicians is known to improve patient safety, however pharmacists have expressed difficulty in developing interprofessional working relationships. There is not a significant body of knowledge around how relationships influence how and when pharmacists and physicians communicate about patient care.

OBJECTIVES

This paper examines how pharmacists and primary care physicians communicate with each other, specifically when they have or do not have an established relationship.

METHODS

Thematic analysis of data from semi-structured interviews with nine primary care physicians and 25 pharmacists, we examined how pharmacists and physicians talk about their roles and responsibilities in primary care and how they build relationships with each other.

RESULTS

We found that both groups of professionals communicated with each other in relation to the perceived scope of their practice and roles. Three emerging themes emerged in the data focusing on (1) the different ways physicians communicate with pharmacists; (2) insights into barriers discussed by pharmacists; and (3) how relationships shape collaboration and interactions. Pharmacists were also responsible for initiating the relationship as they relied on it more than the physicians. The presence or absence of a personal connection dramatically impacts how comfortable healthcare professionals are with collaboration around care.

CONCLUSION

The findings support and extend the existing literature on pharmacist-physician collaboration, as it relates to trust, relationship, and role. The importance of strong communication is noted, as is the necessity of improving ways to build relationships to ensure strong interprofessional collaboration.

Exploring the role of teams and technology in patients' medication decision making

OBJECTIVES

We know little about how electronic health records (EHRs) should be designed to help patients, pharmacists, and physicians participate in interprofessional shared decision making. We used a qualitative approach to understand better how patients make decisions with their health care team, how this information influences decision making about their medications, and finally, how this process can be improved through the use of EHRs.

DESIGN

Participants from 4 regions across Canada took part in a semistructured interview and completed a brief demographic survey. The interview transcripts were thematically analyzed by means of the multidisciplinary framework method.

SETTINGS AND PARTICIPANTS

Thirty participants, 18 years of age and older with at least one chronic illness, were recruited from across Canada. We interviewed participants in their homes, at the school of pharmacy, or another location of their choosing.

RESULTS

We identified 4 main themes: (1) complexity of patient decision making: who, where, what, when, why; (2) relationships with physicians and pharmacists: who do I trust for what?; (3) accessing health information for decision making: how much and from where?; and (4) patients' methods of managing information for health decision making. Across the themes, participants appreciated expert advice from professionals and wanted to be informed about all options, despite concerns about limited knowledge. EHRs were perceived as a potential solution to many of the barriers identified.

CONCLUSION

Patients make decisions with their health care providers as well as with family and friends. The pharmacist and physicians play different roles in helping patients in making decisions. We found that making EHRs accessible not only to health care providers but also to patients can provide a cohesive and clear context for making medication-related decisions. EHRs may facilitate clear communication, foster interprofessional understanding, and improve patient access to their health information. Future research should examine how to develop EHRs that are adaptive to user needs and desires.