Presentation
The Role of Patient Communication Tools in Medication Management After a Regimen Change
SessionDH10 - Poster
Event Type
Poster Presentation
TimeThursday, April 152:38pm - 2:39pm EDT
LocationDigital Health
DescriptionBackground:
Despite the promise of electronic prescribing, medication errors continue to be commonplace under the current system, including errors that can (and do) cause serious harm to patients [1]. One key area for improvement in medication reconciliation practices is the systematic discontinuation of medications [2].
Optimized patient communication tools, such as After-Visit Summaries (AVS) and Patient Portals (PP) could help prevent medication errors. They have the potential to provide clear instructions for the patient and address discrepancies in the medical record, both of which have been shown to reduce error rate [3,4]. Interventions that provide patients with an accurate AVS, including clear medication instructions, have been shown to reduce Medication Dispensation Despite Discontinuation (MDDD) errors and improve patient comprehension [5,6]. Current evidence indicates that existing tools often fail to fulfil this need [7,8]. This study aims to elucidate details about the current utilization of these tools when a medication change occurs and generate recommendations to improve their utility in this context.
Background Section References:
1. Sarkar, U., et al., Adverse drug events in U.S. adult ambulatory medical care. Health Serv Res, 2011. 46(5): p. 1517-33.
2. Fischer, S. and Rose, A., Responsible e-Prescribing Needs e-Discontinuation. JAMA, 2017. 317(5): p. 469-70.
3. Coletti, D.J., et al., Patterns and predictors of medication discrepancies in primary care. Journal of Evaluation in Clinical Practice, 2015. 21(5): p. 831-9.
4. Mira, J.J., et al., Physician patient communication failure facilitates medication errors in older polymedicated patients with multiple comorbidities. Family Practice, 2013. 30: p. 56-63.
5. Ancker, J.S., et al., Health IT Usability Focus Section: Adapting EHR-Based Medication Instructions to Comply with Plain Language Guidance — A Randomized Experiment. Appl Clin Inform, 2017. 8: p. 1127–1143.
6. Graumlich, J.F., et al., Effects of a Patient-Provider, Collaborative, Medication-Planning Tool: A Randomized, Controlled Trial. Journal of Diabetes Research, 2016. 2016: p. 1-16.
7. Neuberger, M., et al., Examination of Office Visit Patient Preferences for the After-Visit Summary (AVS). Perspectives in Health Information Management, Fall 2014. ###: p. 1-8.
8. Federman, A.D., et al., Patient and clinician perspectives on the outpatient after-visit summary: a qualitative study to inform improvements in visit summary design. Journal of the American Medical Informatics Association, 2017. 24(e1): p. e61-e68.
Methods:
This qualitative study examined the role of the AVS & PP during medication changes. It is taking place within a larger quality improvement study examining electronic cancellation messaging and other information sharing practices that occur across the spectrum of care when medications are changed.
This pilot analysis examines preliminary data from one of three study sites, specifically a General Internal Medicine outpatient clinic and affiliated pharmacy. We conducted and completed analysis of four interviews each with prescribers and pharmacy staff. We also incorporated early observations from patient interviews, which are still under analysis. This pilot analysis generated preliminary recommendations for improving the usefulness of the AVS & PP as counseling tools. Additional interviews and analyses are ongoing, and we expect that additional recommendations will emerge.
The preliminary code book utilized deductive codes based on the Systems Engineering Initiative for Patient Safety (SEIPS) model of work system and patient safety, which explores the relationship between structures and processes in a health care system to determine how outcomes are achieved [9]. We have also continued to iteratively and inductively incorporate new codes as additional themes have emerged during the coding process.
Methods Section References:
9. Carayon P, et al. Work system design for patient safety: the SEIPS model. Qual Saf Health Care. 2006;15(Suppl I):i50–i58. doi: 10.1136/qshc.2005.015842
Results & Discussion:
Theme 1: Current Perceptions
• Prescribers have widely varying preferences for using/not using the AVS. They also expressed doubt about whether/how often patients use the AVS.
• Prescribers are often unaware of what aspects of their documentation populate into the AVS. They expressed that the AVS serves different functions for different patients and expressed the desire to customize the generated content accordingly.
• Both prescribers and patients described the AVS as too lengthy and cluttered. This makes it difficult to find key information.
• Prescribers tended to express generally more positive views about the Patient Portal relative to the AVS. However, not all patients utilize MyChart for reasons of both preference and access.
Theme 2: Pharmacy Information Needs
• Pharmacy staff want more information than is currently included in the electronic cancelation (“CancelRx”) messages. They spend a lot of time reviewing the medical record for needed information.
• Pharmacy staff reported that errors are easier to prevent when they know
(1) medication change instructions and (2) the reason for the change. Prescribers aren’t required to enter this information and are usually unaware of what exact information the pharmacy receives.
• All newly prescribed medications are flagged for counseling. Such sessions reinforce patient understanding, which is often incomplete. Information about the reason for change helps optimize this counseling.
Theme 3: Telemedicine and Medication Delivery During the COVID-19 Pandemic
• Most prescribers have not identified a telemedicine alternative to the paper AVS. However, checking medication comprehension can prove easier over telemedicine.
• Pharmacy staff appreciate the extra time for checking documentation to prevent dispensing errors when preparing deliveries. However, delivery can make adherence counseling more challenging, especially when pharmacy staff are not able to successfully connect with the patient by phone.
Resultant Preliminary Recommendations (All Themes):
• Allow patients the option to select preferences for the content and delivery format of the AVS.
• Reduce the amount of auto-populated content in the AVS.
• In the EMR documentation interface, highlight items that will appear in the AVS. Add a check box to certain features (e.g. medication cancellation window) that providers can use to customize content or altogether remove that element from the AVS for that visit.
• Design the medication list in the AVS as a one-page stand-alone document that patients can save for reference. Keep existing graphics that remind the patient about discontinued and new medications. Encourage patients to bring this medication list with them to the pharmacy.
• Convey the medication information that is in the AVS, including start and stop instructions, to the pharmacist. (For example, attach an electronic copy of the medication list portion of the AVS to all CancelRx messages.) Make this an easily printable format so that pharmacists can review it with patients during counseling and/or include it with medication deliveries.
• As long as the option of telemedicine continue, encourage MyChart registration for all telehealth patients. For telehealth patients who do not or cannot use/access MyChart, offer to mail the AVS.
Conclusions:
• Efforts to improve the AVS & PP should incorporate feedback from prescribers, pharmacists, patients, caregivers, and other interdisciplinary care team members.
• The AVS represents a key area for improvement. Efforts should focus on reducing its length and offering ways to tailor the content to the unique needs of each patient.
• In addition to serving as a communication tool for patients, the AVS includes information that might be useful to other members of the care team, including pharmacists.
Despite the promise of electronic prescribing, medication errors continue to be commonplace under the current system, including errors that can (and do) cause serious harm to patients [1]. One key area for improvement in medication reconciliation practices is the systematic discontinuation of medications [2].
Optimized patient communication tools, such as After-Visit Summaries (AVS) and Patient Portals (PP) could help prevent medication errors. They have the potential to provide clear instructions for the patient and address discrepancies in the medical record, both of which have been shown to reduce error rate [3,4]. Interventions that provide patients with an accurate AVS, including clear medication instructions, have been shown to reduce Medication Dispensation Despite Discontinuation (MDDD) errors and improve patient comprehension [5,6]. Current evidence indicates that existing tools often fail to fulfil this need [7,8]. This study aims to elucidate details about the current utilization of these tools when a medication change occurs and generate recommendations to improve their utility in this context.
Background Section References:
1. Sarkar, U., et al., Adverse drug events in U.S. adult ambulatory medical care. Health Serv Res, 2011. 46(5): p. 1517-33.
2. Fischer, S. and Rose, A., Responsible e-Prescribing Needs e-Discontinuation. JAMA, 2017. 317(5): p. 469-70.
3. Coletti, D.J., et al., Patterns and predictors of medication discrepancies in primary care. Journal of Evaluation in Clinical Practice, 2015. 21(5): p. 831-9.
4. Mira, J.J., et al., Physician patient communication failure facilitates medication errors in older polymedicated patients with multiple comorbidities. Family Practice, 2013. 30: p. 56-63.
5. Ancker, J.S., et al., Health IT Usability Focus Section: Adapting EHR-Based Medication Instructions to Comply with Plain Language Guidance — A Randomized Experiment. Appl Clin Inform, 2017. 8: p. 1127–1143.
6. Graumlich, J.F., et al., Effects of a Patient-Provider, Collaborative, Medication-Planning Tool: A Randomized, Controlled Trial. Journal of Diabetes Research, 2016. 2016: p. 1-16.
7. Neuberger, M., et al., Examination of Office Visit Patient Preferences for the After-Visit Summary (AVS). Perspectives in Health Information Management, Fall 2014. ###: p. 1-8.
8. Federman, A.D., et al., Patient and clinician perspectives on the outpatient after-visit summary: a qualitative study to inform improvements in visit summary design. Journal of the American Medical Informatics Association, 2017. 24(e1): p. e61-e68.
Methods:
This qualitative study examined the role of the AVS & PP during medication changes. It is taking place within a larger quality improvement study examining electronic cancellation messaging and other information sharing practices that occur across the spectrum of care when medications are changed.
This pilot analysis examines preliminary data from one of three study sites, specifically a General Internal Medicine outpatient clinic and affiliated pharmacy. We conducted and completed analysis of four interviews each with prescribers and pharmacy staff. We also incorporated early observations from patient interviews, which are still under analysis. This pilot analysis generated preliminary recommendations for improving the usefulness of the AVS & PP as counseling tools. Additional interviews and analyses are ongoing, and we expect that additional recommendations will emerge.
The preliminary code book utilized deductive codes based on the Systems Engineering Initiative for Patient Safety (SEIPS) model of work system and patient safety, which explores the relationship between structures and processes in a health care system to determine how outcomes are achieved [9]. We have also continued to iteratively and inductively incorporate new codes as additional themes have emerged during the coding process.
Methods Section References:
9. Carayon P, et al. Work system design for patient safety: the SEIPS model. Qual Saf Health Care. 2006;15(Suppl I):i50–i58. doi: 10.1136/qshc.2005.015842
Results & Discussion:
Theme 1: Current Perceptions
• Prescribers have widely varying preferences for using/not using the AVS. They also expressed doubt about whether/how often patients use the AVS.
• Prescribers are often unaware of what aspects of their documentation populate into the AVS. They expressed that the AVS serves different functions for different patients and expressed the desire to customize the generated content accordingly.
• Both prescribers and patients described the AVS as too lengthy and cluttered. This makes it difficult to find key information.
• Prescribers tended to express generally more positive views about the Patient Portal relative to the AVS. However, not all patients utilize MyChart for reasons of both preference and access.
Theme 2: Pharmacy Information Needs
• Pharmacy staff want more information than is currently included in the electronic cancelation (“CancelRx”) messages. They spend a lot of time reviewing the medical record for needed information.
• Pharmacy staff reported that errors are easier to prevent when they know
(1) medication change instructions and (2) the reason for the change. Prescribers aren’t required to enter this information and are usually unaware of what exact information the pharmacy receives.
• All newly prescribed medications are flagged for counseling. Such sessions reinforce patient understanding, which is often incomplete. Information about the reason for change helps optimize this counseling.
Theme 3: Telemedicine and Medication Delivery During the COVID-19 Pandemic
• Most prescribers have not identified a telemedicine alternative to the paper AVS. However, checking medication comprehension can prove easier over telemedicine.
• Pharmacy staff appreciate the extra time for checking documentation to prevent dispensing errors when preparing deliveries. However, delivery can make adherence counseling more challenging, especially when pharmacy staff are not able to successfully connect with the patient by phone.
Resultant Preliminary Recommendations (All Themes):
• Allow patients the option to select preferences for the content and delivery format of the AVS.
• Reduce the amount of auto-populated content in the AVS.
• In the EMR documentation interface, highlight items that will appear in the AVS. Add a check box to certain features (e.g. medication cancellation window) that providers can use to customize content or altogether remove that element from the AVS for that visit.
• Design the medication list in the AVS as a one-page stand-alone document that patients can save for reference. Keep existing graphics that remind the patient about discontinued and new medications. Encourage patients to bring this medication list with them to the pharmacy.
• Convey the medication information that is in the AVS, including start and stop instructions, to the pharmacist. (For example, attach an electronic copy of the medication list portion of the AVS to all CancelRx messages.) Make this an easily printable format so that pharmacists can review it with patients during counseling and/or include it with medication deliveries.
• As long as the option of telemedicine continue, encourage MyChart registration for all telehealth patients. For telehealth patients who do not or cannot use/access MyChart, offer to mail the AVS.
Conclusions:
• Efforts to improve the AVS & PP should incorporate feedback from prescribers, pharmacists, patients, caregivers, and other interdisciplinary care team members.
• The AVS represents a key area for improvement. Efforts should focus on reducing its length and offering ways to tailor the content to the unique needs of each patient.
• In addition to serving as a communication tool for patients, the AVS includes information that might be useful to other members of the care team, including pharmacists.
Authors
Human Factors Specialist, Armstrong Institute for Patient Safety and Quality
Assistant Program Director, Armstrong Institute for Patient Safety and Quality