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

Slide Presentation from the AHRQ 2008 Annual Conference

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

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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

Current as of January 2009

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Internet Citation:

Personal Health Records for Medication Use: Views from Elders and Their Physicians. Slide Presentation from the AHRQ 2008 Annual Conference (Text Version). January 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/about/annualmtg08/090908slides/Chrischilles.htm

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