RxSafe: Shared Medication Management and Decision Support for Rural Clinicians (Oregon)

Project Final Report (PDF, 730.79 KB) Disclaimer

Project Details - Ended

Summary:

Managing medications can be complex and difficult in acute care, but is especially challenging for long-term management of older individuals with multiple chronic conditions. Health information technology (IT) may help to improve these processes, but limited progress has been made, especially in patients with multiple conditions who are managed by different clinicians using disparate information systems across many organizations. The purpose of this project was to investigate novel approaches to clinician decision-support applied to multidisciplinary-distributed medication management of people with chronic conditions. The project followed two approaches: 1) improving cognitive support for medication management by exploiting the semantics of clinical information; and 2) improving performance in multidisciplinary clinical work by developing software to facilitate collaboration.

The specific aims of the project were to:

  • Enhance clinician cognitive performance in medication management tasks by exploiting the underlying semantics of medication lists to improve the organization and presentation of medication list information.
  • Implement medication list management tools that are integrated into clinician-specific and task-specific workflows to support medication reconciliation at high-risk transitions as well as in ongoing ambulatory care. 
  • Increase the effectiveness of medication management activities of clinicians in multiple roles by improving their coordination and communication through the use of shared medication management tools.
  • Employ evolving standards and architectures to link external, machine actionable, evidence-based clinical information in context-appropriate ways to support shared medication management by clinicians in ambulatory settings.

Initially, the team: 1) examined medication information in health IT systems, finding great variation in the arrangement and representations of medications among systems; 2) used card sort procedures to reveal that nurses, doctors, and pharmacists organized medications differently depending on task and profession; and 3) used a simulated copying task to find that the order of medications in a list affected recall for novices but not for experienced physicians, and that experienced physicians had greater recall of medications, formed more sophisticated mental models of patients, and spontaneously rearranged  medications when copying a list, suggesting that sense-making accompanies even a simple copying task. 

The team then observed and interviewed nurses, pharmacists, and physicians performing medication review tasks. The team found that medication management in long-term care was a distributed and multidisciplinary process. Clinicians often seek both simple correspondence (“reconciliation”) of items between lists, but also a coherent model of the patient and their care from other data such as diagnoses, comorbidities, laboratory data, and biomedical knowledge. The overall process was seen to be distributed, dynamic, collaborative, and continuous, involving multiple clinicians performing complementary tasks in different settings.

The team used a record locator service/record exchange service model to develop a proof-of-concept system, SyncRx. This system was meant to synchronize medication information in multiple lists maintained by different organizations as medications are asynchronously started, stopped, or changed by doctors, pharmacists, nurses, or others using non-interoperating task-specific applications. The next step in this research will be to test this prototype for usability with clinicians as they interact with the system. 

Finally, the team developed a prototype that demonstrated the feasibility of independent Web-based decision-support services interacting in a service-oriented architecture over a network, including applications to parse medication information, identify and encode medications using existing standards, and enhance this information with Web-based medical knowledge sources.

RxSafe: Shared Medication Management and Decision Support for Rural Clinicians - 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 017102
  • Project Period: 
    September 2007 - August 2011
  • AHRQ Funding Amount: 
    $1,200,000
  • PDF Version: 
    (PDF, 198.15 KB)

Summary: It is widely recognized that health information technology (IT) can improve medical care and patient safety, but questions remain about how best to put health IT systems into practice. This project sought to provide important information about how to integrate decision support into clinical practices to improve the quality and safety of medication management for people with chronic illnesses. This project investigated the feasibility and impact of novel approaches to clinical decision support in multidisciplinary ambulatory care, emphasizing high-risk transitions of care. The project developed technology to support shared medication management for persons with chronic conditions. The health IT system, RxSafe, was used to facilitate clinician decisionmaking and improve outcomes for patients and providers in the management of chronic conditions. Ultimately, the project aimed to show improvements in medication management by: 1) providing the means to effectively share medication information; 2) making any corrections or improvements made by one team member to the regimen visible to all team members; and 3) providing clinicians using the system with access to evidence-based information at the time and place it is needed.

This project is a collaboration between community-based nurses and physicians providing ambulatory services in an Oregon coastal community, a multidisciplinary team of university-based investigators with expertise in medicine, nursing, medical informatics, and computer science, and the Oregon Rural Practice-based Research Network, which provided the infrastructure, coordination, and support. Clinical settings for the project were independent clinic practices in two coastal communities, local home health services, and transitions in care into and out of the sole community hospital and its emergency room. The patient focus was on community-dwelling persons with chronic conditions on multiple medications. The choice of these specific innovations was informed by experience with development and early deployment of RxSafe, a system that consolidates medication lists of patients in long-term care to integrate information for providers involved in prescribing, dispensing, administering, or monitoring medications.

Specific Aims:

  • Enhance clinician cognitive performance in medication management tasks by exploiting the underlying semantics of medication lists to improve the organization and presentation of medication list information. (Achieved)
  • Implement medication list management tools that are integrated into clinician-specific and task-specific workflows to support medication reconciliation at high-risk transitions as well as in ongoing ambulatory care. (Achieved)
  • Increase the effectiveness of medication management activities of clinicians in multiple roles by improving their coordination and communication using shared medication management tools. (Achieved)
  • Employ evolving standards and architectures to link external, machine-actionable, evidence-based clinical information in context-appropriate and user-appropriate ways to support shared medication management by clinicians practicing in ambulatory settings. (Achieved)

2011 Activities: A 1-year no-cost extension allowed for the completion of final project activities including field observations of clinical medication management produced descriptions of cognitive resources and task models. The team evaluated medication management open-source software solutions including MyRxPad, MyMedicationList, and OpenMRS platform. The team configured these clients to interact through the versioning system (SyncRx) and explored the usefulness of this technology in prototype testing to determine the requirements and challenges to its development and deployment.

The team completed the "pipeline" prototype, demonstrating the Web-based clinical decision support model that would allow composition of independent medication information related services. The demonstration included services for parsing, identification using RxNorm, and classification using the National Drug File Reference Terminology of medication information, and a software harness to allow composition of these and other medication management services. Dr. Gorman did not submit a report in the AHRQ Research Reporting System during 2011 with a status of activities or project spending. The project was completed in August 2011.

Impact and Findings: The project found that arrangement of information is important to clinicians and may be an important form of cognitive support. Recall of medication list items corresponded to experience level, with attending physicians recalling a median of 14 of 20 medications overall, residents a median of 10.5 of 20 items, and preclinical students a median of 8.5 items. Student recall was greater with an organized medication list, but resident and attending physician recall was not affected by order, which contrasted with the teams' expectation that the organization of medication information would improve recall yet found data to support this for novices only. However, it may be that processing of the list by the clinician is the more important factor. Recall by experts was high in either case, but subjectively they reported it was easier to recall the list items when they had to reorganize the lists themselves.

Medication reconciliation may occur as an isolated procedure designed to document compliance with regulations. However, medication management in long-term care was a richer, more robust, and more complex process, which is distributed, dynamic, collaborative, and continuous, involving multiple health professionals separately performing complementary tasks in different settings over time. The project was able to demonstrate the technical feasibility of a synchronization system using open-source tools, but further exploration of this prototype is limited to use of open-source tools, including OpenMRS, because of the difficulty of interacting with proprietary closed systems produced by electronic medical record vendors.

A prototype that demonstrated the feasibility of independent Web-based decision support services interacting in a service-oriented architecture over a network was developed. This prototype will allow further exploration of the technical issues encountered, such as differences in drug terminologies used in existing systems, speed or access constraints of Web-based knowledge services, inclusion of extraneous data in medication information fields of local systems, and agreement on useful common classification schema for medication information.

Target Population: Adults, Chronic Care*

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.

RxSafe: Shared Medication Management and Decision Support for Rural Clinicians - 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 017102
  • Project Period: 
    September 2007 – August 2011, Including No-Cost Extension
  • AHRQ Funding Amount: 
    $1,200,000
  • PDF Version: 
    (PDF, 855.57 KB)


Target Population: Adults, Chronic Care*

Summary: It is widely recognized that health information technology (IT) can improve medical care and patient safety, but questions remain about how best to put health IT systems into practice. This project seeks to provide important information about how to integrate decision support into clinical practices to improve the quality and safety of medication management for people with chronic illnesses. This project investigates the feasibility and impact of novel approaches to clinical decision support in multidisciplinary ambulatory care, emphasizing high-risk transitions of care. The project has developed technology to support shared medication management for persons with chronic conditions. This health IT will be used to facilitate clinician decisionmaking, and improve outcomes for patients and providers in the management of chronic conditions. Ultimately, the project aims to show improvements in medication management by 1) providing the means to effectively share medication information, 2) making any corrections or improvements made by one team member to the regimen visible to all team members, and 3) providing clinicians using the system with access to evidence-based information at the time and place it is needed.

This project is a continuation of a successful collaboration between community-based nurses and physicians providing ambulatory services in an Oregon coastal community, a multidisciplinary team of university-based investigators with expertise in medicine, nursing, medical informatics, and computer science, and the Oregon Rural Practice-based Research Network, which provides the infrastructure, coordination, and support. Clinical settings for the project are independent clinic practices in two coastal communities, local home health services, and transitions in care into and out of the single community hospital and its emergency room. The patient focus is on community-dwelling persons with chronic conditions on multiple medications. The choice of these specific innovations was informed by experience with development and early deployment of RxSafe, a system that consolidates medication lists of patients in long-term care to integrate information for providers involved in prescribing, dispensing, administering, or monitoring medications.

Specific Aims:

  • Enhance clinician cognitive performance in medication management tasks by exploiting the underlying semantics of medication lists to improve the organization and presentation of medication list information. (Ongoing)
  • Implement medication list management tools that are integrated into clinician-specific and task-specific workflows to support medication reconciliation at high-risk transitions as well as in ongoing ambulatory care. (Ongoing)
  • Increase the effectiveness of medication management activities of clinicians in multiple roles by improving their coordination and communication using shared medication management tools. (Ongoing)
  • Employ evolving standards and architectures to link external, machine-actionable, evidence-based clinical information in context-appropriate and user-appropriate ways to support shared medication management by clinicians practicing in ambulatory settings. (Ongoing)

2010 Activities: Field observations of clinical medication management tasks remained on track to produce descriptions of cognitive resources and task models during this period (Aims 1, 2). The team evaluated medication management open source software solutions including MyRxPad, MyMedicationList, and OpenMRS platform (Aim 3). The team configured these clients to interact through the versioning system (SyncRx) and explored the usefulness of this technology in prototype testing, to determine the requirements and challenges to its development and deployment (Aim 3).

Pharmacy students were recruited to develop test sets of medication data for evaluating performance of other classification schemas (USP DI, WHO-ATC, and AHFS). Refinement of the documentation for the parser function was completed. The prototype for the identifier module underwent trial-and-error testing. The classifier completed its demonstration phase and began classifying medications automatically using National Drug File Reference Terminology (NDFRT) classes (Aim 4).

The team completed the “pipeline” prototype, demonstrating the Web-based clinical decision support model that would allow composition of independent medication information related services. The demonstration included services for parsing, identification (using RxNorm), and classification (using NDFRT) of medication information, and a software harness to allow composition of these and other medication management services.

A “SyncRx” prototype for collaborative medication management was being developed, based on the Markle Foundation Common Framework for health information exchange, using open source approaches including OpenMRS-based clients as well as client software based on the National Library of Medicine MyRxPad and MyMedicationList software.

Grantee’s Most Recent Self-Reported Quarterly Status (as of September 2010): Project progress is mostly on track, meeting most milestones on time. The project budget was significantly underspent. Funds will be used to underwrite expenses during the no-cost extension. The project is focusing on analysis of field data and disseminating findings from field observation as well as software tools. The team anticipates this will be a major activity moving forward.

Preliminary Impact and Findings: The project team found that nurses, pharmacists, and physicians used different categorization schemes when thinking about medications. Physicians form sophisticated initial mental models of the patient when performing a simple medication reconciliation task, and these models reinforce cognitive performance. Pharmacists and nurses performing medication management tasks identify and correct discrepancies in the medication regimens of their patients in a more complex fashion than what is commonly defined and performed as “medication reconciliation”. This work is embedded in other tasks relating to the total care of the patient. Finally, no publicly-available standard for classifying medications is in use, and this is a major barrier to effective multidisciplinary distributed decision support.

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.

RxSafe: Shared Medication Management and Decision Support for Rural Clinicians - Final Report

Citation:
Gorman PN. RxSafe: Shared Medication Management and Decision Support for Rural Clinicians - Final Report. Prepared by Oregon health & Sciences University under Grant No. R18 HS017102). Rockville, MD: Agency for Healthcare Research and Quality, 2012. (PDF, 730.79 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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