The Impact of Patient Access to Their Electronic Health Record on Medication Management Safety: A Narrative Review

IntroductionAs the American’s Federal Health Insurance Portability and Accountability Act (HIPAA) stated that patients should be allowed to review their medical records, and as information technology is ever more widely used by healthcare professionals and patients, providing patients with online access to their own medical records through a patient portal is becoming increasingly popular. Previous research has been done regarding the impact on the quality and safety of patients’ care, rather than explicitly on medication safety, when providing those patients with access to their electronic health records (EHRs).AimThis narrative review aims to summarise the results from previous studies on the impact on medication management safety concepts of adult patients accessing information contained in their own EHRs.ResultA total of 24 studies were included in this review. The most two commonly studied measures of safety in medication management were: (a) medication adherence and (b) patient-reported experience. Other measures, such as: discrepancies, medication errors, appropriateness and Adverse Drug Events (ADEs) were the least studied.ConclusionThe results suggest that providing patients with access to their EHRs can improve medication management safety. Patients pointed out improvements to the safety of their medications and perceived stronger medication control. The data from these studies lay the foundation for future research.     

Assessment of a medication management program targeting hypertension and diabetes patients: Impact on medication adherence

BackgroundThe National Health Insurance Service in South Korea has conducted a telephone outreach program to improve medication adherence for hypertension and diabetes patients since 2014.ObjectivesTo evaluate the direct outcomes of the program.MethodsPatients were identified among those who visited an outpatient clinic at least twice or used an inpatient service at least once for hypertension or diabetes during 6-month intervals and who were nonadherent based on the proportion of days covered (PDC) calculated. As a preliminary intervention, participants were mailed an information leaflet on their own medication adherence and other tips for effective self-management of chronic diseases. For the intervention, two phone calls and three phone messages were made to patients by 24 participating regional offices. Ultimately, 2,428 hypertension patients and 884 diabetes patients received the intervention. Propensity matching was used based on age, sex, and the Charlson Comorbidity Index to select 12,140 hypertension and 4,420 diabetes patients as controls in the non-participating regions. The outcome was PDC. Multivariate ordinary least squares or logistic regression analysis were used with difference-in-difference specification.ResultsThe adjusted quarterly PDC increased by 1.96%p for hypertension (p = 0.023) and by 7.79%p for diabetes patients (p < 0.001). Approximately 40.6% and 51.7% of hypertension and diabetes patients in the treatment arm (p = 0.0069) became adherent after the intervention, whereas the corresponding proportions were 37.7% and 41.4% (p < 0.001) in the control group. Both treatment groups showed a higher likelihood of good medication adherence (hypertension: odds ratio = 1.157, 95% CI [1.058, 1.265]; diabetes: odds ratio = 1.532, 95% CI [1.323, 1.774]). The control group, who received only a print intervention with a mailed leaflet, also showed a dramatic increase in medication adherence.ConclusionsAn insurer-coordinated telephone-administered program resulted in improvement of medication adherence among patients with hypertension and diabetes.     

How do elderly outpatients manage polypharmacy including DOAC - A qualitative analysis highlighting a need for counselling

BackgroundPatients with polypharmacy are challenged with the management of their daily medication. Medication management strategies for direct oral anticoagulants (DOAC) are especially important to guarantee medication adherence and to prevent thromboembolic events. Patients are often left alone with finding an appropriate strategy.Objective(s)To explore medication management strategies, to measure adherence to DOAC with the aim of deducing recommendations for practice.MethodsFace-to-face semi-structured interviews were conducted at the home of outpatients who were taking ≥4 medications daily including a DOAC, and self-managing their medication. A small electronic device (Time4Med?) was given to record medication intake during the four following weeks. During a second home visit, participants saw a graph of their medication intake as dot chart, and obtained a feedback. Interviews were transcribed verbatim and thematically analysed. Medication adherence was calculated with electronic data.ResultsEighteen individuals (61.1% female; median age 77.5 years) were interviewed and reported 30 different medication management strategies, together with triggers, advantages and limitations. They combined at least five strategies, composed of internal (memory-based) and external (packaging-based or intake-based) strategies. The number of strategies was neither associated with the number of medications nor with medication adherence. Taking adherence was <100% for eight patients (44.4%). The inability of any medication management strategy to adapt to ageing and cognitive decline emerged as its most dramatic limitation, especially because individuals would fail to notice when their strategy became unsuited.ConclusionsElderly patients develop manifold medication management strategies, which can inspire future medication users. Limitations are present such as forgetting medication intake in spite of a management strategy. The moment to adapt the strategy to ageing or cognitive decline is crucial and often goes unnoticed. It is therefore decisive that healthcare professionals regularly re-evaluate the appropriateness of the medication management strategies during counselling or ideally during home visits.     

Pharmacy practice in hospital settings in GCC countries: Dispensing and administration

PurposeTo outline dispensing and administration practices in hospital pharmacy across the Gulf Cooperation Councils (GCC) countries’ hospitals. Paucity of data in appraising hospital pharmacy practice in GCC regions motivated us to conduct this study.MethodsA modified survey questionnaire was prepared from the American Society of Health-System Pharmacist (ASHP) survey questions. Three major domains of questions for general characteristics of the medication use process for dispensing and administration were identified. These were, (1) medication distribution system, and medication distribution technology, (2) technology used to compound sterile preparations, compounding I.V. medication and method of compounding nutrition support preparations, (3) medication administration practices, medication orders, medication administration records (MARs), and technician activities. A list of hospitals was obtained from the Ministry of Health of the targeted GCC countries. A secure invitation link containing a survey questionnaire was sent to the participants directly.ResultsSixty-four hospitals responded to this survey. The overall response rate was 52%. Most surveyed hospitals have centralized inpatient medications distribution system (75.0%). About 37.5% of hospitals used automated dispensing cabinets (ADCs) in their patient care areas. Compounding sterile preparations in the pharmacy, barcode verification technology, workflow management technology, and robotic technology were used by 17.2%, 15.6%, and 4.7% of hospitals, respectively. In using safety technology for medication administration, almost all hospitals have partially or completely implemented an electronic health record (EHR). About 40.6% of hospitals used electronic medication administration records (e-MARs), 20.3% used bar-code-assisted medication administration (BCMA), and 35.9% used smart infusion pumps.ConclusionThe results of this survey revealed an opportunity to improve the medication use management process on dispensing and administration practices in hospitals in GCC countries.     

Safety and efficacy of Rituximab in systemic sclerosis: A systematic review and meta-analysis

PurposeRituximab is widely prescribed to treat systemic sclerosis (SSc) by the depletion of pathogenic B cells. Nonetheless, the clinical benefit of Rituximab in SSc remains contentious. This meta-analysis was conducted to systematically evaluate the safety and efficacy profile of Rituximab in SSc patients.Patients and methodsWe performed a systematic online query in PubMed, Cochrane, and Web of Science. The available studies on the use of Rituximab in SSc patients were comprehensively reviewed and investigated.ResultsIn total, 14 studies, including 597 participants, were analyzed. Pooled results showed the long-term improvement in the modified Rodnan skin score (mRSS) for skin function (ΔmRSS: 7.00 at 6 months, 9.70 at 12 months, and 10.93 at 24 months), while forced vital capacity (FVC) (ΔFVC: −0.69 at 6 months, −2.62 at 12 months, and −0.67 at 24 months) and diffusing capacity of the lungs for carbon monoxide (DLCO) (ΔDLCO: −2.39 at 6 months, −3.28 at 12 months, and −0.79 at 24 months) for lung function remained stable in SSc patients after Rituximab treatment. The rate of Rituximab-related adverse events was 12% in the pooled results.ConclusionThe pooled results of this meta-analysis indicated that Rituximab is well tolerated, and it is able to improve cutaneous function and stabilize pulmonary function in SSc patients.     

Pharmacist-led medication reconciliation at patient discharge: A scoping review

BackgroundOne of the strategies to promote patient safety in care transitions is medication reconciliation (MR), which is conducted by the pharmacist at the patient's discharge from hospital. However, there are divergences about this process and about the pharmacist's role in conducting such intervention.ObjectiveTo systematically review the literature that reports the MR process led by pharmacists at patient discharge and map the different methods, strategies and tools used in the process.MethodsRelevant studies were searched in the following databases: EMBASE, MEDLINE (PubMed), The Cochrane Library, and LILACS. No language restriction or publication date was applied. The studies considered eligible were those involving and describing pharmacist-led MR processes at acute patient discharge from hospital, with an experimental, quasi-experimental, or observational design. The characteristics of the studies and the MR processes were identified and then a qualitative synthesis was performed.ResultsFifty studies were included. The majority of them were observational ones (82%), and the main outcome was medication discrepancies (42%). The studies were mostly conducted in university hospitals (70%) and in internal medicine wards (54%). Pharmacists were responsible mainly for gathering medication histories (72%), and identifying (96%) and solving (98%) pharmacotherapeutic problems. The main sources of information on pre-admission medications were patient/caregiver interviews (66%) and records from other care providers (40%). Only 30% of the studies described a patient discharge plan, and 14% shared information of the patient's pharmacotherapy with community pharmacists.ConclusionThe concept of MR and the pharmacist-led activities in the process varied in the literature, as well as the pharmacotherapy assessment focus and the communication strategies towards patients and other care providers, showing that standardization of the process and concepts is necessary.     

Clinical and economic impact of medication reconciliation by designated ward pharmacists in a hospitalist-managed acute medical unit

BackgroundMinimizing unintended medication errors after admission is a common goal for clinical pharmacists and hospitalists.ObjectiveWe assessed the clinical and economic impact of a medication reconciliation service in a model of designated ward pharmacists working in a hospitalist-managed acute medical unit as part of a multidisciplinary team.MethodsIn this retrospective observational study, we compared pharmacist intervention records before and after the implementation of a medication reconciliation service by designated pharmacists. The frequency and type of intervention were assessed and their clinical impact was estimated according to the length of hospital stay and 30-day readmission rate. A cost analysis was performed using the average hourly salary of a pharmacist, cost of interventions (time spent on interventions), and cost avoidance (avoided costs generated by interventions).ResultsAfter the implementation of the medication reconciliation service, the frequency of pharmacist interventions increased from 3.9% to 22.1% (p < 0.001). Intervention types were also more diverse than those before the implementation. The most common interventions included identifying medication discrepancies between pre-admission and hospitalization (22.7%) and potentially inappropriate medication use in the elderly (13.1%). The median length of hospital stay decreased from 9.6 to 8.9 days (p = 0.024); the 30-day readmission rate declined significantly from 7.8% to 4.8% (p = 0.046). Over two-thirds of interventions accepted by hospitalists were considered clinically significant or greater in severity. The cost difference between avoided cost and cost of interventions was 9838.58 USD in total or 1967.72 USD per month.ConclusionsThe implementation of a designated pharmacist-led medication reconciliation service had a positive clinical and economic impact in our hospitalist unit.