AHRQ 2008 Annual Meeting: Patient–Clinician Communication through Consumer Health IT Presenting: Elizabeth Chrischilles a,b Contributors: Jeanette Daly, c William Doucette, b David Eichmann, d Karen Farris, a,b Brian Gryzlak, a Juan Pablo Hourcade, e Barcey Levy, d Jane Pendergast, a Matthew Witry b The University of Iowa Center for Education and Research on Therapeutics Personal Health Records and Elder Medication Use Quality 1 R18 HS017034-01 a College of Public Health; b College of Pharmacy; c College of Medicine; d Institute for Clinical and Translational Science; e College of Liberal Arts (Computer Science)
Transcript
AHRQ 2008 Annual Meeting: Patient–Clinician Communication through Consumer Health ITPresenting: Elizabeth Chrischillesa,b
Contributors: Jeanette Daly,c William Doucette,b David Eichmann,d Karen Farris,a,b Brian Gryzlak,a Juan Pablo Hourcade,e Barcey Levy,d Jane Pendergast,a Matthew Witryb
The University of Iowa Center for Education and Research on Therapeutics
Personal Health Records and Elder Medication Use Quality1 R18 HS017034-01
a College of Public Health; b College of Pharmacy; c College of Medicine; dInstitute for Clinical and Translational Science; eCollege of Liberal Arts (Computer Science)
The Medicare Modernization Act described the purpose of MTM:
“to optimize therapeutic outcomes (of targeted beneficiaries) through improved medication use, and to reduce the risk of adverse events, including adverse drug interactions”
MTM should include: Targeting of high risk patients Collecting patient information Reviewing complete medication regimen Recommending drug therapy
adjustments Educating patients about medications Monitoring patients’ response to therapy
• Informed and engaged patients get more from MTM
• MTM foundation - Accurate medication list
• Question – Can a PHR increase patient engagement in managing their medications?
I. Patient and physician focus groupsII. Survey of commercially available
PHRsIII. Usability study in human-computer
interaction laboratoryIV. Field test in practice-based research
network
• Gain understanding of– Current patient/physician medication
management practices– Workflow– Barriers to using PHRs in practice
Participants 17 older adults; 4 caregivers 100% white, average age 73.3 ± 6.4, average meds
5.4 ± 2.0; 33% some college & 67% college degree
Many older adults keep a medication list, but not a PHR.
They share lists when they go to health providers, mostly physician visits.
Anything they currently do that approaches a PHR involves a manila folder with everything in it.
Barriers of using a computerized PHR overwhelmed benefits for most. ~50% said they would consider using an
electronic PHR, if they were taught to use and it was simple
Have information if traveling or injured
Can easily share information with numerous physicians or other providers
Family at a distance can access their relative’s health information
#1 barrier was discomfort with security Limiting information to specific providers would be
important, “laboratory persons do not need to see med lists”
Do not want to provide payers with ammunition to limit coverage
Really want doctors and pharmacies to maintain currency of lists/information Keeping a PHR is busy-work Importing information from pharmacy, lab, hospital re
software compatibility is a problem Unsure how physicians or healthcare system will
access electronic PHR from patient May interfere with patient/physician interactions…
“because the doctors are typing instead of listening” Physically typing can be issue
Four Participating Clinics Family medicine clinic at major academic
medical center Multiple physician clinic in small city Rural physician office Residency program in metro area
Invited physicians, nurses, medical assistants, pharmacists, other staff involved with medication management
Medication lists are encouraged by physicians should include herbals are fairly common, especially older adults,
though not always current Useful components of a PHR include
Medication list Past procedures Appointments Immunizations MD contact info Labs, screenings
Dates are important
Patients who move around Patients with complicated diseases ER admissions/New patients Engage patient in their own care Accelerate transfer of health information Decrease duplication Decrease medication errors How PHRs could be used in their practice
Scan into EMR Have medical assistant populate EMR fields
Lack of patient responsibility Cognitively impaired patients Patient computer literacy Patients think it’s the physician’s and
clinic’s job to transfer records Accuracy of information Compatibility with EMR Privacy Manipulation
Narcotic abuse Self diagnosis
about what should be collected in a PHR about the general value of a PHR
▪ Accelerated information sharing about value of PHR for out-of-system or acute care
▪ Health events while traveling, other physicians, new patient/doctor, emergency room
about the lack of value of PHR for regular care▪ Physicians: concern about reliability▪ Patients: busy-work
that computer environment is a major barrier to PHR use▪ Patients: security fears, lack of computer comfort, “I’d have my
son/daughter use it because s/he uses on-line banking.”▪ Patients: may interfere with doctor-patient relationship▪ Physicians: PHR-EMR interface
that most patients won’t maintain a PHR▪ Patients: busy-work▪ Physicians: patients won’t take responsibility to do it
that generally barriers outweigh benefits
about who should maintain the information▪ Patients: providers▪ Providers: patients
Is mobile, travelsHas caregiverSees multiple physiciansHas complex health situationHas conditions requiring self-care
activities Is (or caregiver is) comfortable with
computer
• Reviewed 58 PHRs listed in myphr.org– 54 were operational when we reviewed
them• Most geared towards young families
– Family rather than individual oriented• Few provided easy to access online
demonstrations• Increasingly tied to data entry
services • A majority were poorly designed
– We only found 12 out of 58 could be potentially used in our study
– Problems included
• poorly designed forms• difficult navigation• complex user interfaces
Poor forms: Left-justified labels, limited medication use functionality
Difficult navigation: Too many clicks to access a function
Complex interfaces: Too many options, most of which would be rarely used
PHRs for older adults should meet full medication use functionality; take into account declines in vision, working memory
and motor skills; have simple user interface with large targets for
clicking, larger text, and simple navigation; and comply with standard usability principles or AARP
recommendations on website design for older adults.
Has simple user interface and simple navigation
Designed for mobile, low literacy patient population
Will require a teaching component
Study 1: Study PHR, by age groupStudy 2: Study PHR vs. Prototype PHR• Self-administered questionnaires
– Attitude towards computers– Computer literacy– Health literacy
add new prescription, adjust existing prescription, prescription refills, making note on forgetting to take a prescription, symptom notes, immunizations, add regularly seen doctors
• User satisfaction questionnaire• Debriefing
– Discuss low satisfaction scores, areas where participants have difficulty
