Improving Post-Hospital Medication Management of Older Adults with Health Information Technology (Massachusetts)

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Summary:

Adverse drug events (ADEs), especially those that may be preventable, are among the most serious concerns about medication use in older people in ambulatory settings. A U.S. national surveillance study of emergency department (ED) visits for outpatient ADEs indicated that individuals aged 65 years or older were 2.4 times more likely than younger individuals to sustain ADEs, and nearly 7 times more likely to require hospitalization. Multiple factors, including poor physician-patient communication and education regarding medication use, poor therapeutic monitoring, and incomplete or inaccurate information transfer between clinicians contribute to problematic medication management following acute care. During care transitions, patients receive medications from different prescribers who often lack access to patients’ comprehensive medication lists. In addition, any lack of appropriate followup care exacerbates problems during this vulnerable period.

The goals of this study were to evaluate the impact of providing information through an electronic medical record-based transitional care intervention on the care of older adults discharged from the hospital. The specific aims of the study were to evaluate:

  • The impact of automated scheduling alerts on the rate of followup to an outpatient provider within 14 days of hospital discharge.
  • The impact of automated monitoring alerts on the prevalence of appropriate monitoring for selected high-risk medications within 45 days from the time of hospital discharge.
  • The impact of a health information technology (IT)-based transitional care intervention on the incidence of ADEs within 45 days of hospital discharge.
  • The impact of a health IT-based transitional care intervention on the rate of hospital readmissions and emergency department visits within 30 days of discharge.
  • The costs directly related to the development and installation of the health IT-based transitional care intervention.

A randomized controlled trial of the transitional care intervention that included alerts about key therapeutic changes and monitoring recommendations and followup appointment reminders in a large multispecialty group practice was conducted. This intervention was tested in adults aged 65 and older who had been discharged from the hospital to the ambulatory setting. Randomization of the health IT-discharge communication occurred at the time of hospital discharge.

Significant improvements were not found in visits to the outpatient provider following discharge from the hospital, laboratory monitoring in response to alerts, ADE rates, or rehospitalization and ED visit rates relating to the intervention.

Improving Post-Hospital Medication Management of Older Adults with Health Information Technology - 2011

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS07-006: Ambulatory Safety and Quality Program: Improving Quality Through Clinician Use of Health Information Technology (IQHIT)
  • Grant Number: 
    R18 HS 017203
  • Project Period: 
    September 2007 - August 2011
  • AHRQ Funding Amount: 
    $1,199,952
  • PDF Version: 
    (PDF, 199.44 KB)

Summary: The project employed a randomized controlled trial design to test the ability of a health information technology (IT)-based transitional care intervention that enhanced medication reconciliation and therapeutic monitoring to improve the quality and safety of patient monitoring and medication management. The intervention was integrated into the EpicCare Ambulatory electronic medical record (EMR), and focused specifically on the transition from inpatient to ambulatory settings for older adults who have multiple comorbid conditions and are prescribed high-risk medications. This research examined the quality of followup, outpatient clinician workflow, occurrence of adverse drug events (ADEs), and health care utilization, to gain insight into the effective use of clinical alerts and coordinated delivery of actionable information to outpatient clinicians in the management of ambulatory elderly patients after hospital discharge.

Management of complex information and coordination of data sharing across multiple settings often hamper clinician workflow in the post-hospitalization setting. The intervention addressed these special challenges by automating key steps in the transition of care from the hospital to home, including: 1) expediting and facilitating discharge followup appointment scheduling, including monitoring for no-shows; 2) generating medication lists that alert the primary care provider to key therapeutic additions; and 3) generating patient-specific therapeutic monitoring recommendations for high-risk medications in the post-hospitalization period.

Specific Aims:

  • Evaluate the impact of automated scheduling alerts on the rate of followup to an outpatient provider within 14 days of hospital discharge. (Achieved)
  • Evaluate the impact of automated monitoring alerts on the prevalence of appropriate monitoring for selected high-risk medications at 30 days from the time of hospital discharge. (Achieved)
  • Evaluate the impact of a health IT-based transitional care intervention on the incidence of ADEs within 45 days of hospital discharge. (Achieved)
  • Evaluate the impact of a health IT-based transitional care intervention on the rate of hospital readmissions and emergency department visits within 30 days of discharge. (Achieved)
  • Assess (by level of comorbidity, number of medications, and use of specific high-risk medications) whether a health IT-based transitional care intervention is more effective in subgroups of patients. (Achieved)
  • Determine costs directly related to the development and installation of the health IT-based transitional care intervention. (Achieved)

2011 Activities: The project team conducted two analyses. The first assessed the impact of the intervention on visits to the outpatient provider, hospital readmissions, and emergency department visits. The second analysis determined the investments of time and effort required to develop, test, and launch the EMR-based post-discharge intervention. The latter analysis is a preliminary step for the planned return-on-investment analysis.

The team of clinical research pharmacists continued to review the EMR for ADEs. They also initiated adjudication sessions with the physician reviewers to classify the abstracted events. Due to delays in programming of the EMR, the project team used a 1-year no-cost extension. As last self-reported in the AHRQ Research Reporting System, project progress was completely on track and project budget spending was on target. The project was completed in August 2011.

Impact and Findings: Overall, the project did not find significant improvements in visit rates to outpatient providers following discharge from the hospital, laboratory monitoring in response to alerts, adverse drug event rates, or rehospitalization and emergency department visit rates relating to the intervention.

Visits to the outpatient provider: There were 1,024 visits (54.4 percent of subjects) to an outpatient provider within 14 days of hospital discharge among patients in the intervention group, and 964 in the control group (53.6 percent of subjects).

Laboratory monitoring: Appropriate monitoring for selected high-risk medications within 45 days from time of hospital discharge was 2.35 percent in intervention groups and 1.11 percent in control groups.

Adverse drug events: The first 1,000 hospital discharges for all patients included in the study were comprehensively evaluated, with 514 discharges in the intervention group and 486 discharges in the control group. Among 514 discharges in the intervention group, 107 discharges were identified (20.8 percent), of which there was at least one adverse drug event during the 45-day period after discharge. Among 486 discharges in the control group, 82 discharges were identified (16.9 percent), of which there was at least one adverse drug event during the 45-day period after discharge.

Hospital readmission and emergency department visits: During the 12-month intervention period, in the 30-day period following hospital discharge of the patient, there were 1,884 eligible discharges and 241 rehospitalizations in the intervention group (12.8 percent), and 1797 eligible discharges with 235 rehospitalizations in the control group (13.1 percent). For the same period, again looking at the 30-day period following hospital discharge of the patient, there were 271 emergency department visits in the intervention group (14.4 percent), and 272 emergency department visits in the control group (15.1 percent).

Costs: The total estimate of costs for personnel involved in developing and implementing the transition intervention was $76,314. The time spent on the project across all personnel was 1,308 hours.

Target Population: Elderly*

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve the quality and safety of medication management via the integration and utilization of medication management systems and technologies.

Business Goal: Implementation and Use

* This target population is one of AHRQ's priority populations.

Improving Post-Hospital Medication Management of Older Adults with Health Information Technology - 2010

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS07-006: Ambulatory Safety and Quality Program: Improving Quality Through Clinician Use of Health Information Technology (IQHIT)
  • Grant Number: 
    R18 HS 017203
  • Project Period: 
    September 2007 – August 2011, Including No-Cost Extension
  • AHRQ Funding Amount: 
    $1,199,952
  • PDF Version: 
    (PDF, 732.55 KB)


Target Population: Elderly*

Summary: The project focuses on developing and evaluating the value of an enhanced health information technology (IT) ¬-based medication reconciliation system interfaced with an ambulatory electronic medical record (EMR). It utilizes the EpicCare Ambulatory EMR, which is certified by the Certification Commission for Health Information Technology. The project employs a randomized, controlled trial design to test the health IT-based transitional care intervention with enhanced medication reconciliation and therapeutic monitoring alerts to improve the quality and safety of patient monitoring and medication management. It also focuses specifically on the transition from inpatient to ambulatory settings for older adults who have multiple comorbid conditions and are prescribed high-risk medications. This research allows for the examination of an integrated health IT intervention on the quality of followup, outpatient clinician workflow, occurrence of adverse drug events (ADEs), and health care utilization, to gain insight into the effective use of clinical alerts and coordinated delivery of actionable information to outpatient clinicians in the management of ambulatory elderly patients subsequent to hospital discharge.

The project’s health IT intervention begins with medication reconciliation at the time of hospital discharge. Complex information management and coordination of data sharing across multiple settings often hamper clinician workflow in the post-hospitalization setting. The intervention addresses these special challenges. Specifically, the intervention automates key steps in the transition of care from the hospital to home, including: 1) expediting and facilitating discharge followup appointment scheduling, including monitoring for no-shows; 2) generating medication lists that alert the primary care provider to key therapeutic additions; and 3) generating patient-specific therapeutic monitoring recommendations for high-risk medications in the post-hospitalization period.

Specific Aims:
  • Evaluate the impact of automated scheduling alerts on the rate of followup to an outpatient provider within 14 days of hospital discharge. (Ongoing)
  • Evaluate the impact of automated monitoring alerts on the prevalence of appropriate monitoring for selected high-risk medications at 30 days from the time of hospital discharge. (Ongoing)
  • Evaluate the impact of a health IT-based transitional care intervention on the incidence of ADEs within 45 days of hospital discharge.(Ongoing)
  • Evaluate the impact of a health IT-based transitional care intervention on the rate of hospital readmissions and emergency department visits within 30 days of discharge. (Ongoing)
  • Assess (by level of comorbidity, number of medications, and use of specific high-risk medications) whether a health IT-based transitional care intervention is more effective in subgroups of patients. (Upcoming)
  • Determine costs directly related to the development and installation of the health IT-based transitional care intervention. (Ongoing)

2010 Activities: The project staff completed the development of the therapeutic monitoring guidelines and standards which were reviewed and approved by the research pharmacists, Fallon Clinic (part of the UMass Memorial Medical Group) pharmacy leadership, and medical staff leadership. The Fallon Clinic IT team has used the guidelines to program the intervention.

Preprogramming for the EMR was completed by the Fallon Clinic IT team, and the intervention was launched. Monitoring alerts underwent beta testing for validity, accuracy, and specificity, and the research and programming teams reviewed and refined alerts to minimize alert fatigue in the actual intervention. The programming team developed tracking reports for the research team and the pharmacist abstractors to allow them to follow details of the clinical trial including enrollment and randomization. The project staff began to screen and enroll eligible patients and perform randomization.

Training of the research pharmacists was completed between June and August 2010. Abstraction procedures and the navigation of the EMR were reviewed. The clinical research pharmacists began EMR chart review for ADEs. In addition, the project team is examining outcomes of hospital discharges during the baseline period, defined as the one year prior to the initiation of the intervention. The project team is also reviewing the data collected from project members regarding the time invested relevant to launching the intervention for return on investment analyses.

Grantee’s Most Recent Self-Reported Quarterly Status (as of December 2010): The project is progressing on track, is meeting all milestones, and is on time with all tasks. Project spending is roughly on target. The project is entering its one-year no-cost extension and is focused upon continuing implementation of the intervention, and collecting and analyzing data.

Preliminary Impact and Findings: In July 2010, The American Journal of Managed Care published the study manuscript detailing the therapeutic monitoring guidelines.

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve the quality and safety of medication management via the integration and utilization of medication management systems and technologies.

Business Goal: Implementation and Use

*AHRQ Priority Population.

Improving Post-hospital Medication Management of Older Adults through Health IT - Final Report

Citation:
Gurwitz JH.Improving Post-hospital Medication Management of Older Adults through Health IT - Final Report. (Prepared by University of Massachusetts Medical School under Grant No. R18 HS017203). Rockville, MD: Agency for Healthcare Research and Quality, 2012. (PDF, 130.44 KB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
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