Personal Health Records and Elder Medication Use Quality (Iowa)

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Summary:

Personal health records (PHRs) are an opportunity to increase the involvement of patients in managing their own health. It is believed that increased access to health information through PHR use will increase patient activation and consequently improve patient health behaviors and ultimately health outcomes. There are many documented risks for older adults with their medications. Older adults are vulnerable to medication side effects because of multiple chronic conditions, increased exposure to numerous medications, and the effects of aging on medications’ pharmacokinetic and pharmacodynamic properties. These risks may be better managed by engaging patients in their own care via a PHR.

This research was a collaboration of the University of Iowa Older Adults Center for Education and Research on Therapeutics and the Iowa Research Network. The project conducted a randomized controlled trial among older adults of the effect of a current representative PHR system on patient-reported medication therapy management (MTM) behaviors, beliefs about medications, medication-use quality indicators, and on medication adherence. The specific aims of the project were to:

  • Develop, through patient and provider focus groups, measures of patient MTM behaviors and patient self-efficacy for MTM
  • Compare, in a trial in a primary care Practice-based Research Network, the 6- and 12-month patient-reported MTM behaviors, medication adherence, patient- and physician-centric medication quality indicators, patient self-efficacy for MTM, and patient beliefs about medication, among those randomized to a current, representative PHR system versus those randomized to usual care
  • Investigate the usability of the PHR system in a human-computer interaction laboratory compared with alternative prototypes developed through participatory design with older adults of varying ability levels, and associate PHR performance with measures of cognitive, motor, and perceptual ability

Laboratory sessions compared the usability of a commercial PHR among older versus younger adults. Because all participants had difficulty in the laboratory tasks, especially managing medication information, the research team partnered with a group of adults age 65 and older in 13 sessions over 4 weeks to develop design guidelines for a new PHR. Prototypes of the PHR were tested in focus groups of older adults and the final version tested in a 6-month randomized controlled trial. After completing mailed baseline questionnaires, eligible computer users aged 65 and older were randomized to be given access to the PHR or serve as a standard care control group. Followup questionnaires measured change from baseline medication use, behaviors, quality, and adherence.

Older adults were interested in keeping track of their health and medication information. A majority, 55.2 percent, logged into the PHR and used it, but only 16.1 percent used it frequently. Compared with low/non-users, frequent users reported significantly improved medication management behaviors, reported better medication reconciliation by their providers, and recognized significantly more side effects. There was no difference in quality or adherence measures. PHRs can engage older adults, but features that reduce barriers and motivate continued use must be explored.

Personal Health Records and Elder Medication Use Quality - 2011

Summary Highlights

  • Principal Investigator: 
  • Organization: 
  • Funding Mechanism: 
    RFA: HS07-007: Ambulatory Safety and Quality Program: Enabling Patient-Centered Care through Health Information Technology (PCC)
  • Grant Number: 
    R18 HS 017034
  • Project Period: 
    September 2007 - August 2011
  • AHRQ Funding Amount: 
    $1,199,999
  • PDF Version: 
    (PDF, 198.51 KB)

Summary: The Medicare Modernization Act (MMA) of 2003 required health plans to provide medication therapy management (MTM) services to optimize therapeutic outcomes among high-risk patients with multiple chronic conditions taking multiple medications. Because the MMA did not dictate how health plans should deliver MTM, various delivery methods exist. Regardless of delivery method, a model of patient-centered MTM requires that the patient play a pivotal role in self-monitoring, self-evaluation, goal setting, and medication taking. This project evaluated the ability of a personal health record (PHR) to support and improve elderly patients' medication adherence, use, and management. The project team tested the hypotheses that: 1) a successfully maintained PHR reinforces self-efficacy for MTM; 2) an up-to-date PHR increases patient knowledge about medications; and 3) PHR-gained information allows patients to shift their beliefs about medication from concern to understanding.

Phase I of the project consisted of a series of patient, caregiver, and provider focus groups aimed at identifying patient and physician medication management practices, barriers to PHR use, and physician office workflow issues. Upon evaluating the feedback received during these sessions, the project team identified patients' and providers' wants and needs for the varied functionalities of PHR products, and developed a formal measure of the patients' role in maintaining their health. The team also conducted an environmental scan of commercially available PHR products to identify existing core PHR functions available to elderly patients.

Phases II and III of the project were hands-on trials of patients' interaction with a commercially available PHR. The team tested the PHR by measuring elderly patients' interaction with the technology and their resulting self-activation with respect to medication management. Phase II involved a usability study of the PHR via a human-computer interaction (HCI) laboratory assessment of elderly adults to identify the challenges patients face when using the PHR and the support needed to facilitate usage. After usability testing, it was determined that the commercially available PHR was not well-suited to medication management activities. A new PHR using participatory design methodologies was developed. Subsequently, in Phase III, a randomized controlled trial was conducted comparing older adults using the new PHR with those not using the PHR to assess outcomes, patient-physician communication, and other technology utilization measures.

Specific Aims:

  • Develop measures of patient MTM behaviors and patient self-efficacy for MTM. (Achieved)
  • Compare the patient-reported MTM behaviors, medication adherence, patient- and physician2 | Personal Health Records and Elder Medication Use Quality Ambulatory Safety and Quality: Enabling Patient-Centered Care through Health IT (R18) centric medication quality indicators, patient self-efficacy for MTM, and patient beliefs about medication among patients randomized to a current, representative PHR system versus patients randomized to usual care. (Achieved)
  • Investigate the usability of the PHR system in an HCI interaction laboratory compared with alternative prototypes developed through participatory design with older adults of varying ability levels. Associate PHR performance with measures of cognitive, motor, and perceptual ability. (Achieved)

2011 Activities: Due to delays in the adaptation of the PHR user interface and tracking, the project team used a 1-year no-cost extension that allowed for continued work on this project in 2011. Baseline data was examined by generating frequency distributions and comparing study groups across select characteristics to assess any differences. Survey responses were coded to examine changes over time. Medication data collected at baseline were cleaned and coded using an online interface developed to facilitate this work, and a preliminary assessment of data was completed. The team examined the relationship between multiple chronic conditions and the use of a medication list, and the association of keeping a medication list and patient-provider interaction.

As last self-reported in the AHRQ Research Reporting System, project progress was mostly on track and project budget spending was on target. This project was completed in August 2011.

Impact and Findings: A total of 1,163 people were randomized into the trial; after attrition, 1,075 were included in the analyses. The mean age of the study participants was 72 years; 56.8 percent of participants were women. At baseline, the control group was more likely to have changed the strength or dose of a prescription medication in the past 3 months. At followup, the intervention group was less likely to have started an over-the-counter medication in the previous 3 months than was the control group (8.9 percent versus 13.2 percent), and to be taking two or more nonsteroidal anti-inflammatory drugs (14.1 percent versus 19.4 percent).

Thirty-eight-point-eight percent of the subjects never attempted to log on to the system during the study period. Of those who did, 5.7 percent did not complete the login process, and 4.1 percent completed login but performed no activity with the PHR. More than 40 percent of the intervention group entered at least one medication into the PHR, and the system displayed at least one medication warning message for nearly one-third of them. The most frequent PHR-generated medication warnings were for nonsteroidal anti-inflammatory drugs, angiotensin converting enzyme inhibitors, and acetaminophen.

After adjusting for baseline differences, PHR high-users reported significantly higher over-the-counter medication use at followup compared to PHR low-users and non-users. Significantly more high-users reported keeping a current medication list than did low- and non-users. High-users were also significantly more likely to report having had a side effect in the past 3 months, but they also were more likely to report that they know how to recognize side effects. Upon adjusting for pre-existing differences in the medical problems and number of medications, there was no difference between high-users and low- and non-users in number of medication management problems at followup. Physical health declined from baseline to followup in all user groups. There were no differences observed in health care utilization. Users did not differ in either physical or mental health.

Target Population: Elderly*, Medicare

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient- centered care, the coordination of care across transitions in care settings, and the exchange of electronic health information to improve quality of care.

Business Goal: Implementation and Use

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

Personal Health Records and Elder Medication Use Quality - 2010

Summary Highlights

  • Principal Investigator: 
  • Organization: 
  • Funding Mechanism: 
    RFA: HS07-007: Ambulatory Safety and Quality Program: Enabling Patient-Centered Care through Health Information Technology (PCC)
  • Grant Number: 
    R18 HS 017034
  • Project Period: 
    September 2007 – August 2011, Including No-Cost Extension
  • AHRQ Funding Amount: 
    $1,199,999
  • PDF Version: 
    (PDF, 342.32 KB)


Target Population: Elderly*, Medicare

Summary: Use of medications by older adults living in the community is far from optimal as medication errors including overuse, underuse, and misuse, are common. The Medicare Modernization Act (MMA) of 2003 required health plans to provide medication therapy management (MTM) services to optimize therapeutic outcomes among high-risk patients with multiple chronic conditions taking multiple medications. Because the MMA did not dictate how health plans should deliver MTM, various delivery methods exist. Regardless of delivery method, a model of patient-centered MTM requires that the patient play a pivotal role in self-monitoring, self-evaluation, goal setting, and medication taking. The features of a patient controlled personal health record (PHR) system parallel and are thought to enhance these critical behaviors. By enhancing patient MTM behaviors, the use of PHRs may result in improved patient-provider communication, care continuity, better prescribing, and medication adherence.

The project is evaluating the ability of a PHR to support and improve elderly patients’ medication adherence, use, and management. The team is testing the hypothesis that a successfully maintained PHR provides reinforcement to build self-efficacy for MTM, that an up-to-date PHR increases patient knowledge about medications, and that PHR-gained information allows patients to shift their beliefs about medication from concern to understanding.

Phase I of the project consisted of a series of patient, caregiver, and provider focus groups aimed at identifying patient and physician medication management practices, barriers to PHR use, and physician office workflow issues. Through the evaluation of the feedback received during these sessions, the project team identified patients’ and providers’ wants and needs with respect to the varied functionalities of PHR products and developed a formal measure of the patients’ role in maintaining their health. The project team also conducted an environmental scan of commercially available PHR products to identify existing core PHR functions available to elderly patients. The project team developed a PHR that best met the criteria of the identified core functions.

Phases II and III are hands-on trials of patients’ interaction with the internally developed PHR. The team tested the PHR by measuring elderly patients' interaction with the technology and their resulting self-activation with respect to medication management. Based on Phase I feedback, the project team incorporated patient and provider suggestions into the product. Phase II was a usability study of the PHR, via a human-computer interaction (HCI) laboratory assessment of elderly adults, to identify the challenges patients face when using the PHR, and the support needed to facilitate usage. After Phase II testing, it was determined that the commercially available PHR was not well-suited for medication management activities. A new PHR was therefore developed using participatory design methodologies. Phase III is a randomized controlled trial of the new PHR comparing older adults using the PHR with those randomized to no PHR use across outcomes, patient-physician communication, and other technology utilization measures. Core activities to be analyzed as behavior-based measures of patient participation include keeping an active medication list, recording the purpose of each medication, reporting side effects to providers, and asking questions about medications.

Specific Aims:

  • Develop measures of patient MTM behaviors and patient self-efficacy for MTM. (Achieved)
  • Compare the patient-reported MTM behaviors, medication adherence, patient- and physician-centric medication quality indicators, patient self-efficacy for MTM, and patient beliefs about medication among patients randomized to a current, representative PHR system versus patients randomized to usual care. (Ongoing)
  • Investigate the usability of PHR system in an HCI interaction laboratory compared with alternative prototypes developed through participatory design with older adults of varying ability levels. Associate PHR performance with measures of cognitive, motor, and perceptual ability. (Ongoing)

2010 Activities: As part of the PHR development process, staff incorporated most of the "desirable" functions as identified through their earlier focus group and participatory design sessions. In addition, they incorporated detailed tracking functionality to enable them to describe the PHR user experience. Seventeen medication messages, grounded in Assessing Care of Vulnerable Elderly quality indicators, were developed and are displayed to PHR users upon entry of a trigger medication. The messages were evaluated by two physicians and two pharmacists and the study team implemented revisions based upon their feedback. Each resulting message contains three levels of increasingly detailed information. Three focus groups with older adults were conducted to elicit feedback on the PHR prototype (University of Iowa version). In two of the sessions, the team presented the medication entry form to participants and asked for feedback on PHR layout and functionality. For the remaining session, the team presented examples of draft medication messages and received feedback on layout, structure, and content.

At the end of 2010, questionnaires were sent to 2,372 people who were eligible for the trial per their screening questionnaire responses. Of these individuals, 1,176 completed and returned baseline questionnaires, for a response rate of 49.6 percent. The team randomized individuals (at a 3:1 ratio) and sent invitations and a quick start guide to use the PHR (PHR group), or a thank you letter (control group) to 840 and 280 people, respectively.

Grantee’s Most Recent Self-Reported Quarterly Status (as of December 2010): Project progress is mostly on track, and project spending is roughly on target. The intervention is underway and the project team is focused upon collection and analysis of qualitative and quantitative data.

Preliminary Impact and Findings: Findings from the focus groups with family physicians suggested that providers predominantly view PHRs as a backup source of medical information, secondary to the patient’s medical record, as opposed to a tool for patients. While providers believe PHRs have the potential to decrease errors and increase efficiency, they are concerned about how to integrate PHRs into patient visits that are already too short. Preliminary results revealed that older users were much less likely to be able to complete key medication-related tasks using the commercial PHR system. For example, whereas 69 percent of younger users were able to successfully enter medications into the system, the same was true for only 25 percent of older users. All younger users were able to successfully change the strength of a medication, while only 25 percent of older users were able to do so.

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the exchange of electronic health information to improve quality of care.

Business Goal: Implementation and Use

*AHRQ Priority Population.

Personal Health Records and Elder Medication Use Quality - Final Report

Citation:
Chrischilles EA. Personal Health Records and Elder Medication Use Quality - Final Report. (Prepared by the University of Iowa under Grant No. R18 HS017034). Rockville, MD: Agency for Healthcare Research and Quality, 2012. (PDF, 550.31 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.
Principal Investigator: 
Document Type: 

Personal Health Record (PHR) Focus Group Questions for Older Adults

This is a focus group guide designed to be conducted with patients within a home setting. The tool includes questions to assess user's perceptions of personal health records.

Year of Survey: 
Created prior to 2010
Survey Link: 
Personal Health Record (PHR) Focus Group Questions for Older Adults (PDF, 74.48 KB)
Document Type: 
Research Method: 
Population: 
Care Setting: 
Copyright Status: 
Permission has been obtained from the survey developers for unrestricted use of this survey; it may be modified or used as is without additional permission from the authors.
Organization: 
Location: 

Physician Focus Group Guide Personal Health Record (PHR) and Medication Management Activities

This is a focus group guide designed to be conducted with physicians in an ambulatory setting. The tool includes questions to assess user’s perceptions of personal health records.

Year of Survey: 
Created prior to 2010
Survey Link: 
Physician Focus Group Guide Personal Health Record (PHR) and Medication Management Activities (PDF, 55.66 KB)
Document Type: 
Research Method: 
Population: 
Care Setting: 
Copyright Status: 
Permission has been obtained from the survey developers for unrestricted use of this survey; it may be modified or used as is without additional permission from the authors.
Organization: 
Location: 
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