The Electronic Pharmaceutical Record: A new method for medication reconciliation

Effects of physician-led medication reconciliation on the outcomes of outpatients utilizing the PharmaCloud system

BACKGROUND

Taiwan introduced PharmaCloud, a system designed to streamline access to comprehensive medication records from various healthcare settings. Despite its potential, the impact of physician-led medication reconciliation (MR) utilizing PharmaCloud on outpatient outcomes remains unclear. This study aims to address this gap by evaluating the effectiveness of PharmaCloud-enabled MR in improving patient outcomes.

METHODS

We collected data from outpatients with major polypharmacy (≥ 10 medications) between May 19, 2019, and April 18, 2020, comparing those who received MR with those who did not. Outcomes including total medical expenditures, ED visits, hospitalizations, mortality rate, and number of medications were compared between the two cohorts over a 12-month follow-up period.

RESULTS

The study enrolled 209 patients with MR and 9,053 patients without MR. Patients who received MR were older, had lower body mass index, took more medications, and had a higher prevalence of hypertension, cerebrovascular disease, chronic kidney disease, and mental disorder. After 12 months of follow-up, patients who received MR had a higher proportion of reduced medications (adjusted odds ratio: 1.4; 95% confidence interval: 1.0 - 2.0), but also had more ED visits in the first 12 months compared to those who did not receive MR. The study did not find any significant differences in total medical expenditures, hospitalizations, and mortality rates between the two cohorts.

CONCLUSIONS

The model reduced medication use. Further research, including prospective designs, pharmacist involvement, and evaluations of reduced complications from fewer medications, is needed to better clarify patient outcomes.

Value Propositions for Digital Shared Medication Plans to Boost Patient-Health Care Professional Partnerships: Co-Design Study

BACKGROUND

Health authorities worldwide have invested in digital technologies to establish robust information exchange systems for improving the safety and efficiency of medication management. Nevertheless, inaccurate medication lists and information gaps are common, particularly during care transitions, leading to avoidable harm, inefficiencies, and increased costs. Besides fragmented health care processes, the inconsistent incorporation of patient-driven changes contributes to these problems. Concurrently, patient-empowerment tools, such as mobile apps, are often not integrated into health care professional workflows. Leveraging coproduction by allowing patients to update their digital shared medication plans (SMPs) is a promising but underused and challenging approach.

OBJECTIVE

This study aimed to determine the value propositions of a digital tool enabling patients, family caregivers, and health care professionals to coproduce and co-manage medication plans within Switzerland's national eHealth architecture.

METHODS

We used an experience-based co-design approach in the French-speaking region of Switzerland. The multidisciplinary research team included 5 patients as co-researchers. We recruited polypharmacy patients, family caregivers, and health care professionals with a broad range of experiences, diseases, and ages. The experience-based co-design had 4 phases: capturing, understanding, and improving experiences, followed by preparing recommendations and next steps. A qualitative, participatory methodology was used to iteratively explore collaborative medication management experiences and identify barriers and enabling mechanisms, including technology. We conducted a thematic analysis of participant interviews to develop value propositions for digital SMPs.

RESULTS

In total, 31 persons participated in 9 interviews, 5 focus groups, and 2 co-design workshops. We identified four value propositions for involving patients and family caregivers in digital SMP management: (1) comprehensive, accessible information about patients' current medication plans and histories, enabling streamlined access and reconciliation on a single platform; (2) patient and health care professional empowerment through the explicit co-ownership of SMPs, fostering coresponsibility, accountability, and transparent collaboration; (3) a means of supporting collaborative interprofessional medication management, including tailored access to information and improved communication across stakeholders; and (4) an opportunity to improve the quality of care and catalyze digital health innovations. Participants discussed types of patient involvement in editing shared information and emphasized the importance of tailoring SMPs to individual abilities and preferences to foster health equity. Integrating co-management into the clinical routine and creating supportive conditions were deemed important.

CONCLUSIONS

Coproduced SMPs can improve medication management by fostering trust and collaboration between patients and health care professionals. Successful implementation will require eHealth interoperability frameworks that embrace the complexity of medication management and support diverse use configurations. Our findings underscored the shared responsibility of all stakeholders, including policy makers and technology providers, for the effective and safe use of SMPs. The 4 value propositions offer strategic guidance, while highlighting the need for further research in different health care settings.

Discrepancies in Electronic Medical Prescriptions Found in a Hospital Emergency Department: A Prospective Observational Study

The medication in an electronic prescribing system (EPS) does not always match the patient's actual medication. This prospective study analyzes the discrepancies (any inconsistency) between medication prescribed using an EPS and the medication revised by the clinical pharmacist upon admission to the observation area of the emergency department (ED). Adult patients with multimorbidity and/or polypharmacy were included. The pharmacist used multiple sources to obtain the revised medication list, including patient/carer interviews. A total of 1654 discrepancies were identified among 1131 patients. Of these patients, 64.5% had ≥1 discrepancy. The most common types of discrepancy were differences in posology (43.6%), commission (34.7%), and omission (20.9%). Analgesics (11.1%), psycholeptics (10.0%), and diuretics (8.9%) were the most affected. Furthermore, 52.5% of discrepancies affected medication that was high-alert for patients with chronic illnesses and 42.0% of medication involved withdrawal syndromes. Discrepancies increased with the number of drugs (ρ = 0.44, p < 0.01) and there was a difference between non-polypharmacy patients, polypharmacy ones and those with extreme polypharmacy (p < 0.01). Those aged over 75 years had a higher number of prescribed medications and discrepancies occurred more frequently compared with younger patients. The number of discrepancies was larger in women than in men. The EPS medication record requires verification from additional sources, including patient and/or carer interviews.

Patients' Use of a Standardized Medication List - A Mixed Methods Study

Purpose

A medication list (ML) is a document listing the patient's entire medication, instructions for use, and indications. In Germany, a national standard was established in 2016 by law. However, data on patients' use of this standardized ML are scarce. We investigated (i) patients' practical use of the ML, (ii) patients' understanding of the ML, (iii) completeness and correctness of the current ML version, and (iv) reasons why patients did not adhere to their ML.

Patients and Methods

Community pharmacists recruited patients possessing a standardized ML with ≥5 medications. Information sources to evaluate the ML were: (a) brown bag analysis, (b) practical demonstration, (c) patient interview, and (d) patient file. Data were analyzed using qualitative and quantitative methods.

Results

Two hundred and eighty-eight patients (median age: 76 years, range: 27-95) were enrolled. (i) 38.5% of the patients used their ML regularly to prepare their medication and 73.3% to inform their physician. (ii) Overall, patients' understanding of the ML was good, with >80% of the patients being able to identify all relevant information. (iii) While n = 2779 medications were actually taken, n = 2539 were documented on the ML. No ML was fully correct and complete. Regarding particularly relevant items, ie, active ingredient, strength, dosage, medication missing or listed but not taken, 79.2% of ML were incorrect or incomplete. Handwritten modifications on the ML were frequent. (iv) Almost 60% of all patients did not follow their ML with "fear of adverse drug reactions" being the most frequently (n = 50) mentioned reason.

Conclusion

Completeness and correctness of the current ML version was poor with handwritten modifications being frequent. Additionally, most of the patients did not adhere to their ML. This indicates that measures that lead to correct and up-to-date ML and improvements in patient counseling about their medication should be developed and implemented into routine practice.

[Contribution of the pharmaceutical record in the analysis of drug interactions during retrocession in a centre for cancer research]

OBJECTIVES

To implement the pharmaceutical record in retrocession, to evaluate its contribution to the analysis of drug interactions and to estimate the sustainability of this approach.

METHODS

This prospective, descriptive, monocentric study was conducted over five months. All patients presenting at the retrocession were eligible. After having offered them the pharmaceutical record and having completed it, drug interactions were sought. If the impact was considered significant, a pharmaceutical intervention was transmitted to the referring physician of the institution and recorded in the computerized patient record.

RESULTS

The pharmaceutical record was offered to 497 patients, i.e., 87 % of eligible patients. At the first meeting, 7 % of patients (n=34) were aware of it and 72 % had one open. In total, 395 pharmaceutical records were filled in at least once, 41 of which we created. Only 25 patients (5 %) refused the process and 90 % of the existing records were filled by the pharmacy. In total, 419 prescriptions were analysed for 330 patients: the pharmaceutical record was therefore a useful tool for 66 % of patients. For 17 % (n=57) of them, or 11 % of included patients, 99 drug interactions with a high risk of clinical impact were detected with the retroceded drug. On average, the presentation, creation and feeding of the drug record took one minute each and the analysis of interactions 14minutes.

CONCLUSIONS

Easy to implement, the pharmaceutical record is a useful tool to search for drug interactions with retroceded drugs. It helps to optimize patient follow-up, despite the limited information available.

Optimizing Hospital Electronic Prescribing Systems: A Systematic Scoping Review

OBJECTIVE

Considerable international investment in hospital electronic prescribing (ePrescribing) systems has been made, but despite this, it is proving difficult for most organizations to realize safety, quality, and efficiency gains in prescribing. The objective of this work was to develop policy-relevant insights into the optimization of hospital ePrescribing systems to maximize the benefits and minimize the risks of these expensive digital health infrastructures.

METHODS

We undertook a systematic scoping review of the literature by searching MEDLINE, Embase, and CINAHL databases. We searched for primary studies reporting on ePrescribing optimization strategies and independently screened and abstracted data until saturation was achieved. Findings were theoretically and thematically synthesized taking a medicine life-cycle perspective, incorporating consultative phases with domain experts.

RESULTS

We identified 23,609 potentially eligible studies from which 1367 satisfied our inclusion criteria. Thematic synthesis was conducted on a data set of 76 studies, of which 48 were based in the United States. Key approaches to optimization included the following: stakeholder engagement, system or process redesign, technological innovations, and education and training packages. Single-component interventions (n = 26) described technological optimization strategies focusing on a single, specific step in the prescribing process. Multicomponent interventions (n = 50) used a combination of optimization strategies, typically targeting multiple steps in the medicines management process.

DISCUSSION

We identified numerous optimization strategies for enhancing the performance of ePrescribing systems. Key considerations for ePrescribing optimization include meaningful stakeholder engagement to reconceptualize the service delivery model and implementing technological innovations with supporting training packages to simultaneously impact on different facets of the medicines management process.

Medicines Reconciliation in the Emergency Department: Important Prescribing Discrepancies between the Shared Medication Record and Patients’ Actual Use of Medication

Medication reconciliation is crucial to prevent medication errors. In Denmark, primary and secondary care physicians can prescribe medication in the same electronic prescribing system known as the Shared Medication Record (SMR). However, the SMR is not always updated by physicians, which can lead to discrepancies between the SMR and patients’ actual use of medication. These discrepancies may compromise patient safety upon admission to the emergency department (ED). Here, we investigated (a) the occurrence of discrepancies, (b) factors associated with discrepancies, and (c) the percentage of patients accessible to a clinical pharmacist during pharmacy working hours. The study included all patients age ≥ 18 years who were admitted to the Hvidovre Hospital ED on three consecutive days in June 2020. The clinical pharmacists performed medicines reconciliation to identify prescribing discrepancies. In total, 100 patients (52% male; median age 66.5 years) were included. The patients had a median of 10 [IQR 7–13] medications listed in the SMR and a median of two [IQR 1–3.25] discrepancies. Factors associated with increased rate of prescribing discrepancies were age < 65 years, time since last update of the SMR ≥ 115 days, and patients’ self-dispensing their medications. Eighty-four percent of patients were available for medicines reconciliations during the normal working hours of the clinical pharmacist. In conclusion, we found that discrepancies between the SMR and patients’ actual medication use upon admission to the ED are frequent, and we identified several risk factors associated with the increased rate of discrepancies.

Improving Primary Care Medication Processes by Using Shared Electronic Medication Plans in Switzerland: Lessons Learned From a Participatory Action Research Study

Background

Several countries have launched health information technology (HIT) systems for shared electronic medication plans. These systems enable patients and health care professionals to use and manage a common list of current medications across sectors and settings. Shared electronic medication plans have great potential to improve medication management and patient safety, but their integration into complex medication-related processes has proven difficult, and there is little scientific evidence to guide their implementation.

Objective

The objective of this paper is to summarize lessons learned from primary care professionals involved in a pioneering pilot project in Switzerland for the systemwide implementation of shared electronic medication plans. We collected experiences, assessed the influences of the local context, and analyzed underlying mechanisms influencing the implementation.

Methods

In this formative action research study, we followed 5 clusters of health care professionals during 6 months. The clusters represented rural and urban primary care settings. A total of 18 health care professionals (primary care physicians, pharmacists, and nurses) used the pilot version of a shared electronic medication plan on a secure web platform, the precursor of Switzerland’s electronic patient record infrastructure. We undertook 3 group interviews with each of the 5 clusters, analyzed the content longitudinally and across clusters, and summarized it into lessons learned.

Results

Participants considered medication plan management, digitalized or not, a core element of good clinical practice. Requirements for the successful implementation of a shared electronic medication plan were the integration into and simplification of clinical routines. Participants underlined the importance of an enabling setting with designated reference professionals and regular high-quality interactions with patients. Such a setting should foster trusting relationships and nurture a culture of safety and data privacy. For participants, the HIT was a necessary but insufficient building block toward better interprofessional communication, especially in transitions. Despite oral and written information, the availability of shared electronic medication plans did not generate spontaneous demand from patients or foster more engagement in their medication management. The variable settings illustrated the diversity of medication management and the need for local adaptations.

Conclusions

The results of our study present a unique and comprehensive description of the sociotechnical challenges of implementing shared electronic medication plans in primary care. The shared ownership among multiple stakeholders is a core challenge for implementers. No single stakeholder can build and maintain a safe, usable HIT system with up-to-date medication information. Buy-in from all involved health care professionals is necessary for consistent medication reconciliation along the entire care pathway. Implementers must balance the need to change clinical processes to achieve improvements with the need to integrate the shared electronic medication plan into existing routines to facilitate adoption. The lack of patient involvement warrants further study.