Challenges Faced by Health Professionals in Obtaining Correct Medication Information in the Absence of a Shared Digital Medication List

Identifying Medication Review Topics to Be Documented in a Structured Form in Electronic Health Record Systems: Delphi Consensus Survey

BACKGROUND

Poor data transfer and interoperability between electronic health record (EHR) systems has been a challenge hindering availability and usability of patient information in clinical practice and evidence-based decision-making. To improve data transfer and interoperability, patient information should be documented in a structured format. This also applies to medication-related patient information and results of the interventions, such as medication reviews (MRs), to individually optimize medication regimens, especially in older adults.

OBJECTIVE

This study aimed to identify what information obtained from MRs should be documented in a structured form in EHRs at a national and organizational level.

METHODS

The study was conducted as a 3-round Delphi consensus survey in 2020. The electronic survey was based on a comprehensive inventory of international and national MR procedures in various settings. Expert panelists (N=41) independently assessed which topics should be documented in a structured form in EHRs. The interprofessional panel (N=41) consisted of 12 physicians, 13 pharmacists, 10 nurses, and 6 information management professionals (participation rate 66%-76% in rounds 1-3; consensus limit set at 80%). The responses were analyzed quantitatively and qualitatively.

RESULTS

Consensus was reached on 97.3% (108/111) of predetermined topics to be documented in a structured form in EHRs. Of these, 39 concerned the MR process, 25 related to potentially drug-induced symptoms, 11 related to burden of risks for adverse drug effects, 12 related to laboratory tests and other test results, 12 related to medication adherence, and 9 related to the use of intoxicants. The patient's blood pressure (mean 4.85, SD 0.53; on a Likert scale 1-5), kidney function (mean 4.81, SD 0.56), and risk of bleeding (mean 4.81, SD 0.56) were ranked as the 3 most important topics to be documented in a structured form. The panel reached a consensus that the information obtained from MRs should be made available to all health care professionals in the national digital repository for patient data and to patients to some extent.

CONCLUSIONS

The interprofessional expert panel strongly agreed on the results of the MRs that should be documented in a structured form in EHRs and made available to both health professionals involved in care teams and patients themselves.

Toward a National Information Model for Medication Orders in Sweden

Semantic interoperability among health information systems (HISs), in particular electronic health records (EHRs), is crucial for informed healthcare decisions and access to vital health data by the patient. However, inconsistent medication information and limited health data exchange contribute to medication errors worldwide. Although Sweden offers various solutions for health information exchange, there is a limitation in the exchange of medication orders and a lack of understanding the structure of medication orders among EHRs, highlighting the need for further exploration of the structure of medication orders.This study aims to develop a common information model of medication orders for EHRs to be used in the Swedish context.An explorative qualitative design study was conducted. Documents and reference models of how medication orders are structured were collected, and semi-structured interviews were conducted with five purposefully selected participants with insight into how medication orders are structured in EHRs in Sweden. Data were analyzed using information needs analysis, information structure analysis, and code systems, classifications, and terminology analysis.The following information areas were identified for a medication order: medication, medication indication, way of administration, medication order details, and dosage. These information areas were conceptualized into a Unified Modeling Language Class Diagram information model with defined classes, attributes, and data types. The resulting information model provides a representation of how medication orders are depicted in EHRs in Sweden and is aligned with existing national information models such as the National Medication List, while still providing additional information related to medication order details.The developed information model could potentially provide a national standardized model for medication orders, contributing to enhanced semantic interoperability and improving data exchange across various HISs. This could enhance data consistency, reducing the risk of medication errors and thereby improving patient safety.

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.

Health professionals' experience and perceived obstacles with managing patients' medication information in Norway: cross-sectional survey

BACKGROUND

Access to correct and up to date medication information is crucial for effective patient treatment. However, persistent discrepancies exist. This study examines the experiences and challenges health professionals encounter while utilizing current digital solutions in the Norwegian healthcare system to manage patients' medication information.

METHODS

A cross-sectional descriptive analysis using quantitative survey data was conducted to investigate how health professionals managed patients' medication information. Content analysis was used to analyze free-text responses concerning challenges they encountered when transferring medication information and to identify factors deemed necessary for implementing the Shared Medication List in Norway.

RESULTS

A total of 262 doctors and 244 nurses responded to the survey. A higher percentage of doctors (72.2%) expressed concerns regarding obtaining accurate and updated medication lists than nurses (42.9%), particularly for patients with polypharmacy (35.3%) or transitioning between primary and specialist care services (27.6%). The patient's verbal information was the main source for hospital doctors (17%) to obtain an overview of the patient's medication usage, while general practitioners (19%) and nurses (working in both primary and specialist care services, 28% and 27% respectively) predominantly relied on electronic prescriptions. Doctors, in particular general practitioners, reported carrying excessive responsibilities in coordinating with other health actors (84.8%) and managing patients' medication information. The vast majority of both doctors (84.4%) and nurses (82.0%) were in favor of a Shared Medication List. However, about a third of doctors (36.3%) and nurses (29.8%) expressed the need for a more balanced responsibility in updating and managing patients' medication information, while ensuring compatibility with existing digital systems.

CONCLUSIONS

Fragmented resources for medication information and unclear responsibilities were prevalent concerns among both professional groups. Doctors voiced more concern than nurses about the accuracy of patients' medication list. While both groups are positive about a shared medication list, successful implementation requires proactive training initiatives and clearer role clarification.

Healthcare professionals' perceptions of a web-based application for using the new National Medication List in Sweden

Objective

During the first stage of implementing the National Medication List in Sweden, a web-based application called Förskrivningskollen (FK) was launched. FK includes information about a patient's prescribed and dispensed medications, and it works as a backup system until the healthcare electronic health record (EHR) systems are fully integrated. The aim of this study was to examine the healthcare professionals' experiences and perceptions of FK.

Methods

The study applied a mixed methods approach, with statistics about the use of FK and a survey with open and closed questions. The respondents (n  =  288) were healthcare professionals who were users or potential users of FK.

Results

Overall there was little knowledge about FK and uncertainty regarding working routines and the regulations connected to the application. Lack of interoperability with the EHRs made FK time-consuming to use. Respondents said that the information in FK was not updated, and they were concerned that using FK could lead to a false sense of security about the accuracy of the list. Most clinical pharmacists thought FK added benefit to their clinical work, while as a group, physicians were more ambivalent about FK's benefit.

Conclusions

The concerns of healthcare professionals give important insights for future implementation of shared medication lists. Working routines and regulations linked to FK need to be clarified. In Sweden, the potential value of a national shared medication list will probably not be realized until it is fully integrated into the EHR in a way that supports healthcare professionals' desired ways of working.

Implementation of E-prescription for Multidose Dispensed Drugs: Qualitative Study of General Practitioners' Experiences

Background

Increased use of pharmaceuticals challenges both capacity and safety related to medication management for patients and changes in how general practitioners (GPs) and other health personnel interact with and follow up with patients. E-prescribing of multidose drug dispensing (eMDD) is 1 of the national measures being tested in Norway.

Objective

The objective of this study is to explore GPs’ experiences with the challenges and benefits of implementing eMDD in Norway.

Methods

Qualitative in-depth and group interviews were conducted with a total of 25 GPs between 2018 and 2020. Transcribed files were saved in NVivo to conduct a step-by-step content analysis. NVivo is a software tool for organizing, managing, and analyzing qualitative data.

Results

The study revealed that eMDD offers many benefits. At the same time, there are several challenges related to information, training, and initiation, as well as to the responsibility for the medication, interactions, and the risk of incorrect medication. An important activity in the start-up phase was an information meeting with pharmacies and technology suppliers, as well as exchanging information and instructions with pharmacies on how to get started. Four analytic themes emerged through the extraction of data: (1) start-up with eMDD (“Be patient”); (2) the need for training; (3) interaction, safety, and efficiency; and (4) the working day with eMDD.

Conclusions

There is a variation in different GPs’ needs regarding training and information, and considerable variation in competence and motivation related to the use of digital tools. There are also different degrees of understanding the everyday work of the other actors in the medication chain. In particular, the harmonization of medication lists related to the use of time, expenditures, and challenges with technological solutions in the introduction phase was emphasized as a challenge. Overall, GPs who have started using the system report great benefits; these are largely related to an increased overview of patients’ total medication lists, less time spent on prescribing prescriptions, and increased collaboration with pharmacies and nurses, both in service from providers in homes and in nursing homes.

Issues with the Swedish e-prescribing system - An analysis of health information technology-related incident reports using an existing classification system

OBJECTIVE

To identify issues with the Swedish e-prescribing system and devise a set of recommendations to overcome the identified challenges.

METHODS

A number of health information technology-related incidents were collected retrospectively from various sources using purposive and snowball sampling. A search term containing five keywords was used to identify the electronic prescription-related incidents. The identified incidents (n = 24) were subjected to an existing framework, i.e., the Health Information Technology Classification System. Special attention was paid to the software-related issues, which were analysed using thematic analysis.

RESULTS

Several types of software-related issues (n = 22) were identified: system configuration, interface with other software systems or components, software functionality, data storage and backup, record migration, software not accessible, and network/server down or slow. Both human and technical factors contributed to these incidents, including prescriptions not cancelled actively, drug handling errors, software programming errors, and system updates/upgrades. These software problems led to various consequences, such as incidents affecting multiple patients' care management, delays in patient care, and risks of serious deterioration of health. Several temporary initiatives or administrative adjustments, for instance, cover letters to patients and local strategies, were used to overcome some of these challenges.

CONCLUSIONS

This study provides insights into the challenges related to the e-prescribing system, contributing factors, consequences, and actions taken to mitigate those risks. Therefore, healthcare organisations using the e-prescribing system should adopt the provided recommendations to minimise the risks of design and developmental challenges, implementation and use-related issues, and the problems related to monitoring, evaluation, and optimisation.

Implementation of a shared medication list in primary care - a controlled pre-post study of medication discrepancies

Background

Access to medicines information is important when treating patients, yet discrepancies in medication records are common. Many countries are developing shared medication lists across health care providers. These systems can improve information sharing, but little is known about how they affect the need for medication reconciliation. The aim of this study was to investigate whether an electronically Shared Medication List (eSML) reduced discrepancies between medication lists in primary care.

Methods

In 2018, eSML was tested for patients in home care who received multidose drug dispensing (MDD) in Oslo, Norway. We followed this transition from the current paper-based medication list to an eSML. Medication lists from the GP, home care service and community pharmacy were compared 3 months before the implementation and 18 months after. MDD patients in a neighbouring district in Oslo served as a control group.

Results

One hundred eighty-nine patients were included (100 intervention; 89 control). Discrepancies were reduced from 389 to 122 (p <  0.001) in the intervention group, and from 521 to 503 in the control group (p = 0.734). After the implementation, the share of mutual prescription items increased from 77 to 94%. Missing prescriptions for psycholeptics, analgesics and dietary supplements was reduced the most.

Conclusions

The eSML greatly decreases discrepancies between the GP, home care and pharmacy medication lists, but does not eliminate the need for medication reconciliation.