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; Plugin Software Help).
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).
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."
- 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 personal health record (PHR) increase patient engagement in managing their medications?
- Patient and physician focus groups.
- Survey of commercially available PHRs.
- Usability study in human-computer interaction laboratory.
- Field test in practice-based research network.
Focus Group Study Aims
- Gain understanding of:
- Current patient/physician medication management practices.
- Barriers to using PHRs in practice.
Patient Focus Group 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%
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.
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.
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.
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.
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.
- MD contact info.
- Labs, screenings.
- Dates are important.
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.
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.
- Narcotic abuse.
- Self diagnosis.
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.
Patients and Physicians Disagree.
- About who should maintain the information:
- Patients: providers.
- Providers: patients.
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.
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.
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.
- Has simple user interface and simple navigation.
- Designed for mobile, low literacy patient population.
- Will require a teaching component.
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.
- Discuss low satisfaction scores, areas where participants have difficulty.
Current as of January 2009
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