Personal Health Records for Medication Use: Views from Elders and Their Physicians

AHRQ 2008 Annual Conference

Slide Presentation from the AHRQ 2008 Annual Conference

On September 9, 2008, Elizabeth Chrischilles, made this presentation at the 2008 Annual Conference. Select to access the PowerPoint® presentation (1.8 MB).

Slide 1

Personal Health Records for Medication Use: Views from Elders and Their Physicians

AHRQ 2008 Annual Meeting: Patient—Clinician Communication through Consumer Health Information Technology (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).

Slide 2

Medication Therapy Management (MTM) Background

• 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."

Slide 3

MTM Background

• 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.

Slide 4

Research Question

• Informed and engaged patients get more from MTM.
• MTM foundation—Accurate medication list.
• Question—Can a personal health record (PHR) increase patient engagement in managing their medications?

Slide 5

Study Design

1. Patient and physician focus groups.
2. Survey of commercially available PHRs.
3. Usability study in human-computer interaction laboratory.
4. Field test in practice-based research network.

Slide 6

Focus Group Study Aims

• Gain understanding of:
  • Current patient/physician medication management practices.
  • Workflow.
  • Barriers to using PHRs in practice.

Slide 7

Patient Focus Group Participants

• 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.
• Pie chart for Self-Rated Health (n=21)
  • Excellent: 9%
  • Very Good: 33%
  • Good: 48%
  • Fair: 5%
  • Poor: 5%
• Pie chart for Marital Status (n=21)
  • Never Married: 5%
  • Divorced: 19%
  • Widowed: 14%
  • Married: 62%

Slide 8

Patient Focus Group Results

• 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.

Slide 9

Patient-Perceived Benefits of Computerized PHR

• 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.

Slide 10

Patient-Perceived Barriers to Computerized PHR

• #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.

Slide 11

Physician Focus Group Participants

• 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.

Slide 12

Physician Focus Group Results

• 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.

Slide 13

Physician-Perceived Benefits of PHRs

• Patients who move around.
• Patients with complicated diseases.
• Emergency room (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 Electronic Medical Record (EMR).
  • Have medical assistant populate EMR fields.

Slide 14

Physician-Perceived Barriers to PHRs

• 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.

Slide 15

Patients and Physicians Agree...

• 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.

Slide 16

Patients and Physicians Disagree.

• About who should maintain the information:
  • Patients: providers.
  • Providers: patients.

Slide 17

The Ideal Candidate for a PHR

• Is mobile, travels.
• Has caregiver.
• Sees multiple physicians.
• Has complex health situation.
• Has conditions requiring self-care activities.
• Is (or caregiver is) comfortable with computer.

Slide 18

Survey of PHRs

A screen shot of the homepage from the Web site, www.myphr.com.

• 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.

Slide 19

Examples of PHR Problems

• 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.
  • Comply with standard usability principles or AARP recommendations on Web site design for older adults.

Slide 20

Study PHR

• Has simple user interface and simple navigation.
• Designed for mobile, low literacy patient population.
• Will require a teaching component.

Slide 21

Next Step: Planned Usability Evaluations of PHR

• Study 1: Study PHR, by age group.
• Study 2: Study PHR vs. Prototype PHR.
  • Self-administered questionnaires
    • Attitude towards computers.
    • Computer literacy.
    • Health literacy.
• PHR tasks
  • Think aloud protocol.
  • Measure efficiency and effectiveness.
  • Sample tasks: login, physician visit, add existing prescriptions, 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.

Slide 22

Thank you