Optimizing Medication History Value in Clinical Encounters with Elderly Patients (Virginia)

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Summary:

Some electronic prescribing (e-prescribing) systems connect to networks that allow for real-time information on medication history from commercial pharmacies to be available to prescribers. Electronic medication histories that include prescription fill information enhance a clinician’s ability to provide quality medication management. Knowledge about a patient’s adherence to previously prescribed regimens can improve communication between patients and clinicians. This may allow for the engagement of patients in making decisions about their medications, particularly around regimens that a patient is more likely to adhere to. However, additional training on the use of these electronic medication histories is needed to optimize improvements in the quality of medication management during a patient encounter.

This project developed geriatric-specific algorithms for use in e-prescribing systems to alert clinicians to potential problems during medication management. The project team developed continuing medical education (CME) modules to educate clinicians about the use of medication information when prescribing to improve safety and patient-provider communication. Finally, they evaluated the impact of the algorithms and the CME modules on medication management. 

The main objectives of this project were to:

  • Develop geriatric-specific algorithms to identify potential issues with medication management (e.g., polypharmacy, potentially inappropriate medication use, duplicative therapy, and nonadherence) using community pharmacy-generated medication history.
  • Develop structured, problem-oriented frameworks for organizing medication history information during visits (triggering) for common issues identified by the algorithms developed in the first aim. 
  • Develop and pretest modules to teach clinicians how to improve geriatric patient-provider communication relating to medication management with the use of technology (training). 
  • Test the impact of these interventions on clinician behavior using a randomized controlled trial with two arms: 1) delivery of triggers; and 2) delivery of triggering and training interventions. 
  • Develop "tool-kit" resources and intervention products for use by non-physician providers in other ambulatory settings (e.g., pharmacists in community pharmacy settings).

Thirty-three physicians were recruited and randomized to two interventions: 14 to the algorithms alone, and 19 to the algorithms combined with the CME modules. A multi-modal evaluation was completed using surveys of patients, focus groups of physicians, analysis of taped clinical encounters, and the tracking of e-prescribing data.

The project team found that physicians were open to evidence-based treatment algorithms, as long as alerts were designed to promote efficiency and reduce redundancy. It was found that alternatives to potentially inappropriate medications should be provided to clinicians during prescribing to make it easier for the clinicians to choose those alternatives. The study did not show a change in clinician perception of e-prescribing, nor of patient perception of patient-physician communication. Physicians overrode alerts frequently across both arms of the study. Physicians indicated frustration with alerts that provided commonly known information, and repetitive, previously overridden alerts. The project team noted a need to suppress alerts when medications were renewed for a patient currently taking and tolerating a medication well.

Optimizing Medication History Value in Clinical Encounters with Elderly Patients - 2011

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS07-006: Ambulatory Safety and Quality Program: Improving Quality through Clinician Use of Health Information Technology (IQHIT)
  • Grant Number: 
    R18 HS 017150
  • Project Period: 
    September 2007 - September 2011
  • AHRQ Funding Amount: 
    $1,199,989
  • PDF Version: 
    (PDF, 197.25 KB)

Summary: Electronic prescribing (e-prescribing) combined with a medication history may assist physicians in more fully understanding adherence issues with older patients, promoting clinician-patient partnerships, empowering patients to participate in treatment decisions, and allowing patients to negotiate acceptable medication regimens that are more amenable to patient follow-through. Some e-prescribing systems are integrated with pharmacy chains, making medication histories and information on unfilled prescriptions available to clinicians.

This project was designed to assess whether clinician training on medication history could improve its use during the clinical encounter and optimize improvement in the quality of medication management in ambulatory settings. In addition, the project examined the role of electronic medication management tools in helping clinicians to identify potential medication management problems and to monitor complex medication regimens.

Dr. Lapane's team developed geriatric-specific algorithms to identify potential medication management issues - such as polypharmacy, potentially inappropriate medication use, duplicative therapy, and nonadherence - when using community pharmacy-generated medication histories. The team used these algorithms to collaborate with electronic medical record (EMR) and e-prescribing software vendors to integrate problem-oriented "triggers" at the point of prescribing, which organized medication history information for reference during visits.

The team also developed and pre-tested four Web- or DVD-based continuing medical education (CME) training modules that were used to conduct clinician trainings. Module content focused on how to improve geriatric patient-provider communication relating to medication management with the use of technology-based tools.

Physicians who used the e-prescribing application and network to transmit prescriptions to pharmacies were recruited and a two-arm randomized controlled study to test this intervention was conducted. Half the practices received the e-prescribing software, which included triggering based on medication history information. The other half received the software with triggers and were given the opportunity to complete the CME training modules.

Specific Aims:

  • Develop geriatric-specific algorithms to identify potential issues with medication management (e.g., polypharmacy, potentially inappropriate medication use, duplicative therapy, and nonadherence) using community pharmacy-generated medication history. (Achieved)
  • Develop structured, problem-oriented frameworks for organizing medication history information during visits (triggering) for common issues identified by the algorithms developed in the first aim. (Achieved)
  • Develop and pretest modules to teach clinicians how to improve geriatric patient-provider communication relating to medication management with the use of technology (training). (Achieved)
  • Test the impact of these interventions on clinician behavior using a randomized controlled trial with two arms: 1) delivery of triggers; and 2) delivery of triggering and training interventions. (Achieved)
  • Develop "tool-kit" resources and intervention products for use by nonphysician providers in other ambulatory settings (e.g., pharmacists in community pharmacy settings). (Achieved)

2011 Activities: During the first 3 years of the project, the research team developed the algorithms and worked with an e-prescribing software developer to learn how medication data were captured and to finalize the specific triggers. An EMR vendor then coded these triggers. By the end of 2010 all participating physicians had the triggers installed in their e-prescribing solution.

Recruitment of physicians from Virginia Commonwealth University was completed in summer 2011. In order to be eligible, physicians were required to use one of two e-prescribing systems and had to provide comprehensive care. In addition, eligibility required that at least 25 percent of each physician's patient case mix be over 65 years of age, and providers had to be willing to be randomized to one of the intervention arms. A total of 33 doctors were randomized to the two previously developed intervention arms; 14 to algorithms in software, and 19 to algorithms in software and opportunity to complete the CME training modules.

Patient surveys were collected before and after the intervention period to capture patient perceptions of medication-related issues with their providers. Five clinical encounters were audio recorded for each physician. Patient survey data and physician audio data were coded to assess the quality of patient-provider interactions about medications. Data for each medication were coded into themes including general information, knowledge of the drug, discussion of the prescription, and effects of the drug. The coding scheme allowed the team to capture the extent of contribution of each party to medication-related discussions during medical encounters.

As last self-reported in the AHRQ Research Reporting System, project progress and activities were completely on track, and project budget spending was roughly on target. Dr. Lapane's team utilized a 1-year no-cost extension to ensure adequate time for recruitment, implementation, analysis, and dissemination, and the project was completed in September 2011.

Impact and Findings: Evidence-based treatment algorithms were well received by primary care physicians. Providing alternatives to potentially inappropriate medications would make it easier for physicians to change decisions at the point of prescribing. No changes were found in physician perceptions of e-prescribing or in the patient perceptions of physician communication. Physicians overrode alerts often, and this did not vary by treatment arm.

Target Population: Elderly*

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve the quality and safety of medication management via the integration and utilization of medication management systems and technologies.

Business Goal: Implementation and Use

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

Optimizing Medication History Value in Clinical Encounters with Elderly Patients - 2010

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS07-006: Ambulatory Safety and Quality Program: Improving Quality through Clinician Use of Health Information Technology (IQHIT)
  • Grant Number: 
    R18 HS 017150
  • Project Period: 
    September 2007 – September 2011
  • AHRQ Funding Amount: 
    $1,199,989
  • PDF Version: 
    (PDF, 547.47 KB)


Target Population: Elderly*

Summary: Electronic prescribing (e-prescribing) combined with a medication history may help physicians better understand adherence issues with older patients. These systems promote clinician-patient partnerships, empower patients to participate in treatment decisions, and help clinicians to negotiate acceptable medication regimens that are more amenable to patient follow-through. Some e-prescribing systems are integrated with pharmacy chains, making medication histories and information on unfilled prescriptions available to clinicians.

Stemming from Dr. Lapane’s previous research, this project explores the hypothesis that in order to optimize improvements in quality of medication management during clinician office visits, clinicians need additional training to improve their use of the medication history in the clinical encounter. The research team also hypothesizes that additional clinical information systems must be used in conjunction with the flow of detailed medication history via e-prescribing to help guide and structure the clinician's approach to medication management in ambulatory settings.

The project aims to test information technology (IT) by leveraging the flow of community pharmacy-based medication history at the point of prescribing, coupled with training to enhance patient-provider communication. The project is focused on improving medication management among elderly people seeking care in ambulatory care settings. Specifically, the intervention strives to aid in the evaluation and prioritization of medication management issues at the point of prescribing, incorporating medication information into the clinical encounter, and fostering the clinician-geriatric and patient-caregiver communication regarding potential medication management issues. The purpose of the intervention is to improve the facilitation of informed, shared decisionmaking and monitoring for medication-related problems, and assist clinicians in evaluating and monitoring complex medication regimens to help identify, resolve, and prevent medication-related problems.

In order to test this intervention, the project will conduct a large-scale randomized trial, recruiting physicians that use DrFirst, an e-prescribing application and network to transmit prescriptions to pharmacies. One-half of the practices will receive the innovative modality for delivery of the standard of care by leveraging medication history information to generate triggers or alerts; the other half will receive the triggers plus training. The evaluation of the project relies on extensive process tracking, existing data sources of medication history, and primary data collection of provider information.

Specific Aims:

  • Develop geriatric-specific algorithms to identify potential issues with medication management (e.g., polypharmacy, potentially inappropriate medication use, duplicative therapy, and nonadherence) using community pharmacy-generated medication history. (Achieved)
  • Develop structured, problem-oriented frameworks for organizing medication history information during visits (triggering) for common issues identified by the algorithms developed in Aim 1. (Achieved)
  • Develop and pretest modules to teach clinicians how to improve geriatric patient-provider communication relating to medication management with the use of technology (training). (Achieved)
  • Test the impact of these interventions on clinician behavior using a randomized controlled trial with two arms: 1) delivery of triggers; and 2) delivery of triggering and training interventions. (Ongoing)
  • Develop "tool-kit" resources and developed intervention products for use by nonphysician providers in other ambulatory settings (e.g., pharmacists in community pharmacy settings). (Achieved)

2010 Activities: While physician practice recruitment has started, it has remained a significant challenge. The intervention has been administered to those randomized to the treatment arm.

The research team worked with the e-prescribing software developer, DrFirst, to finalize the specific triggers and to review additional issues as needed. This process was informed by the analysis of secondary data to confirm what had been learned from earlier systematic reviews. The triggers have been implemented, and all physicians participating in the study have had the triggers installed in their e-prescribing solution.

In order to code the physician-patient interaction, physicians are audio taping a small number of clinical encounters at baseline and followup. The research team worked closely with the developers of the Medicode System to develop and test a protocol for coding patient-physician communication. All baseline audio tapes were submitted for coding.

The team identified a few areas for improvement for the physician training modules, and updated the Web site and CD modules to include the changes. They also used Articulate software to convert the training modules into a more effective format. Each CD contains one module, and the plan is for each physician to receive one module every 10 days for four waves.

Grantee’s Most Recent Self-Reported Quarterly Status (as of December 2010): The project budget is underspent primarily because a substantial portion of the budget is tied to participant recruitment, as well as coding of clinical encounters. Spending will be on target following enrollment phase. Project progress is on track in some respects but not in others due to challenges in recruitment.

Preliminary Impact and Findings: To date, physicians are more likely to use the CDs than the Web-based modules. The CDs have also been tested in training other health professions about drug issues experienced by older adults, and the team has confirmed that the content is appropriate for this wider audience.

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve the quality and safety of medication management via the integration and utilization of medication management systems and technologies.

Business Goal: Implementation and Use

*AHRQ Priority Population.

Optimizing Medication History Value in Clinical Encounters with Elderly Patients - Final Report

Citation:
Lapane K. Optimizing Medication History Value in Clinical Encounters with Elderly Patients - Final Report. (Prepared by Virginia Commonwealth University under Grant No. R18 HS017150). Rockville, MD: Agency for Healthcare Research and Quality, 2012. (PDF, 328.67 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.
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