Using Information Technology for Patient-Centered Communication and Decisionmaking about Medications (Illinois)

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Using Information Technology for Patient-Centered Communication and Decisionmaking about Medications - 2011

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS07-007: Ambulatory Safety and Quality Program: Enabling Patient-Centered Care through Health Information Technology (PCC)
  • Grant Number: 
    R18 HS 017220
  • Project Period: 
    September 2007 - August 2011
  • AHRQ Funding Amount: 
    $1,199,997
  • PDF Version: 
    (PDF, 183.89 KB)

Summary: Medication errors are a major source of patient injury, hospitalization, and death. Medication management in primary care is extremely complicated because of the continually expanding array of available therapies, fragmentation of care, proliferation of information sources, and numerous obstacles experienced by patients (e.g., cost). This study integrated interventions that target patients, providers, and the overall practice system in an effort to improve the medication management process.

The overarching objective of this multicomponent intervention was to develop a protocol to reconcile medications through the phases of the patient-provider clinical encounter. The project provided patient education materials and medication lists automatically extracted from Epic Systems' electronic medical record (EMR), EpicCare to adults enrolled in the project. In advance of their physician visit at a multispecialty primary care center, patients received the materials, reviewed the medication information contained within the system, and indicated if there were any discrepancies or if they had any related questions or concerns. The nurse reviewed the patient-provided information and placed the output into the rooming sheet for the physician. The system encouraged physicians to engage in shared decisionmaking by including prompts to elicit questions and concerns and ways to tailor treatment plans to match patients' needs and abilities. The physician clarified any issues with the patient and updated the patient's medication list in the EMR. When new medication was prescribed, the system generated a plain-language medication information sheet for the patient. The information sheet was automatically generated through project-developed "dot phrases" (system macros that automatically fill in descriptive text prompted by key words) in the EMR, an enhancement made to the existing functionality of the EpicCare EMR.

The clinic was organized into four areas (pods) with separate nursing staff and physicians and the clustered, controlled clinical trial was randomized at this "pod" level. Through post-visit interviews and data extracted from the EMR, the project assessed post-visit discrepancies in the medication list, the patient's functional understanding of his/her medication regimen, questions on adherence and safety, and a series of process measures to verify that the intervention was translatable to other organizations.

Specific Aims:

  • Develop and test a multimedia program (which was revised to an educational print piece) to help patients understand the importance of both giving and receiving accurate information about medications (pre-visit patient intervention). (Achieved)
  • Use the EMR to encourage patient-centered medication management. (Achieved)
  • Work with the practice-based research network to disseminate and track the use of effective interventions, and create pathways for facilitating national distribution to other practices. (Achieved)

2011 Activities: The 12-month no-cost extension enabled data collection activities to be completed and the team to focus on obtaining data reports and cleaning data. There were some difficulties obtaining the final target recruitment numbers. At one site, aspects of the intervention were turned off when the EMR was rebooted; however, there was no effect on the overall progress and data quality. As last self-reported in the AHRQ Research Reporting System, project progress and activities were on track in some respects but not others and project budget spending was on target. All project activities were completed when the project ended in August 2011.

Impact and Findings: The researchers on this project found gains in reducing discrepancies related to prescription omissions in the medication list. Fewer gains were achieved in reducing discrepancies related to removing medicines no longer being taken and adding omitted non-prescription regimens patients report taking daily. Key informant interviews alluded to physician barriers not addressed by the intervention; for example, desire not to remove another physician's order, lack of perceived salience of non-prescription medicines, lack of time for more complicated regimens, and failure to change the EMR at the time of the visit. Findings to date have substantial value in understanding how best to change existing practices to ensure medication reconciliation, education, and counseling when new medication is prescribed.

Several-hundred medication sheets were developed through this project. These are tangible products that have been widely accepted by physicians as assisting in improving and managing patient care.

Target Population: Adults

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

Business Goal: Implementation and Use

Using Information Technology for Patient-Centered Communication and Decisionmaking about Medications-2010

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS07-007: Ambulatory Safety and Quality Program: Enabling Patient-Centered Care through Health Information Technology (PCC)
  • Grant Number: 
    R18 HS 017220
  • Project Period: 
    September 2007 – August 2011, Including No-Cost Extension
  • AHRQ Funding Amount: 
    $1,199,997
  • PDF Version: 
    (PDF, 356.98 KB)


Target Population: Adults

Summary: Medication errors are a major source of patient injury, hospitalization, and death. Medication management in primary care is extremely complicated, given the continually expanding array of available therapies, fragmentation of care, proliferation of information sources, and numerous obstacles experienced by patients (e.g., cost). This study integrates interventions that target patients, providers, and the overall practice system in an effort to improve the medication management process.

The overarching objective of this multicomponent intervention is to develop a protocol to reconcile medications through the phases of the patient-provider clinical encounter. The project provides patient education materials and medication lists that are automatically extracted from the Certification Commission for Health Information Technology-certified Epic Systems’ electronic medical record (EMR), EpicCare. Patients receive the materials in advance of their physician visit at the multispecialty primary care center. Patients then review the medication information contained within the system, indicating if there are any discrepancies or if they have any related questions or concerns. The nurse reviews the patient-provided information and places the output into the rooming sheet for the physician. The system encourages physicians to engage in shared decisionmaking by including prompts for eliciting questions and concerns as well as tailoring treatment plans to match patients’ needs and abilities. The physician will then clarify any issues with the patient and update the patient’s medication list in the EMR. If a new medication is prescribed, the system will generate a plain-language medication information sheet for the patient. The information sheet is automatically generated through project-developed “dot phrases” (system macros that automatically fill in descriptive text prompted by key words) in the EMR, an enhancement to the existing functionality of the Epic EMR.

The clustered, controlled clinical trial will be randomized at the “pod” level to reflect the clinic’s organization into four areas (pods) with separate nursing staff and physicians. Through post-visit interviews and data extracted from the EMR, the project will assess post-visit discrepancies in the medication list, the patient’s functional understanding of their medication regimen, questions on adherence and safety, and a series of process measures to assure that the intervention is translatable to other organizations.

Specific Aims:
  • Develop and test a multimedia program (which has been since revised to an educational print piece) to help patients understand the importance of both giving and receiving accurate information about medications (pre-visit patient intervention). (Achieved)
  • Use the EMR to encourage patient-centered medication management and extend the EMR medication management capability by training nurses to engage in a patient-centered review of current medications immediately before a patient sees the doctor. Leverage the EMR by developing a template that physicians can easily access to engage in a patient-centered discussion about new medications under consideration. (Achieved)
  • Work with the practice-based research network to disseminate and track the use of effective interventions, and create pathways for facilitating national distribution to other practices. (Ongoing)

2010 Activities: The team continued to engage in discussions with the Information Technology (IT) Leadership Team and General Internal Medicine practice directors to discuss options for pre-populating the EMR with medication information sheets and how they will be used by the physicians during the intervention. The study team also utilized health literacy experts to provide interim and final feedback on content and format. Once completed, the medication information sheets were pre-populated into the EMR by the IT team.

A second pilot test was completed in January 2010 with two physicians and feedback was collected from the physicians to refine the intervention. A training session was performed at a physician meeting and followup e-mails were sent out to clarify any concerns. A trial run of the intervention was implemented in February 2010 to work out final problems and address physicians' concerns before starting recruitment.

The team modified the intervention so patients could receive the educational print folder at the end of their visit. The previous protocol had patients obtain this folder when they checked in for their visit and many patients lost or misplaced it by the end of the visit.

Data collection for the medication reconciliation portion of this study started in February and was completed in July. A total of 163 patients were recruited; 88 control and 75 intervention. The data are currently being analyzed. Data collection for the patient knowledge portion of this study began in December 2010 and will take approximately 6 months to complete.

Grantee’s Most Recent Self-Reported Quarterly Status (as of December 2010): Progress is mostly on track and the project is meeting most of its milestones. Project spending is roughly on target.

Preliminary Impact and Findings: One hundred and forty-four patients were enrolled with 69 in the control group and 75 in the intervention group. An additional 19 patients were excluded from analysis because they were seen by residents. Overall, 85 percent of patients had some type of discrepancy in their EMR medication list; however, no significant differences were found between the control and intervention groups in overall discrepancies. Types of discrepancies have been broken down to omissions, such as medications taken that are not on their list; commissions, such as medications on their list that they are not taking; and duplications. Overall, 18 percent of patients had at least one omission, 44 percent had at least one commission, and 29 percent had at least one duplication. No significant differences were found between control and intervention groups in type of discrepancy. The current medications evaluation study data are still being analyzed.

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

Business Goal: Implementation and Use

Project Details - Ended

Project Categories

Summary:

Medication errors are a significant source of patient injury, hospitalization, and even death. The management of medication information requires a partnership between a patient and their caregivers in order to reconcile the medications a patient is thought to be taking with medications they are actually taking. This project looked at the integration of patient-centered interventions targeting patients, their providers, and their healthcare organization in an attempt to improve the medication management process. The focus was on using electronic medical record (EMR)-based tools to improve patients’ understanding of their prescribed medication regimens.

The interventions included the use of: 1) print materials; 2) standardized medication instructions that generate more patient-friendly and explicit prescription instructions; 3) EMR protocols and codes to upload materials and cue their generation either at the point of check-in to the clinic or at the time of a new order; and 4) a process for delivering the intervention that acknowledges common challenges in primary care.

The main objectives of the project were to:

  • Develop and test a multimedia program (which was revised to an educational print piece) to help patients understand the importance of both giving and receiving accurate information about medications (pre-visit patient intervention).
  • Use the EMR to encourage patient-centered medication management and extend the EMR medication management capability by training nurses to engage in a patient-centered review of current medications immediately before a patient sees the doctor. Leverage the EMR by developing a template that physicians can easily access to engage in a patient-centered discussion about new medications under consideration.
  • Work with the practice-based research network to disseminate and track the use of effective interventions, and create pathways for facilitating national distribution to other practices.

The project evaluated the interventions via two randomized pre-post controlled evaluations. The first evaluation focused on EMR-based efforts to improve a patient’s understanding of new medications prescribed; the second study focused on EMR-based efforts to reconcile medication lists prior to a medical encounter to reduce discrepancies.

At the end of the funded project term, the first evaluation is still in progress. In the second evaluation, the project team found that they improved the ability to reduce discrepancies as related to omissions of prescriptions on the medication list. However, they had less success reducing discrepancies related to having medications on the medication list that are no longer being taken, and the lack of non-prescription medications on the list. Interviews with clinicians revealed barriers that were not addressed by the project’s intervention. These included an unwillingness to remove a medication ordered by another physician; a lack of perceived relevance of non-prescription medications; and a lack of time to enter complicated regimens into the EMR at the time of the visit.

Using Information Technology for Patient-Centered Communication and Decisionmaking about Medications - Final Report

Citation:
Wolf M. Using Information Technology for Patient-Centered Communication and Decisionmaking about Medications - Final Report. (Prepared by Northwestern University under Grant No. R18 HS017220). Rockville, MD: Agency for Healthcare Research and Quality, 2012. (PDF, 1.02 MB)

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: 
This project does not have any related survey.
This project does not have any related story.
This project does not have any related emerging lesson.