Standardised electronic information exchange between nurses in home care and GPs – the medication information processes

Abstract

Improving the transfer of medication information between home care nurses and patient’s general practitioners (GP) is assessed as essential for ensuring safe care. In this paper, we report on a Norwegian study in which we investigated how home care nurses experienced using standardised electronic messages in their communication with the GPs. Standardised electronic solutions were developed and implemented to resolve gaps in the medication information processes when patients received nursing care in their homes. Data was collected combining focus group interviews and individual interviews with nurses from home care in two municipalities in Norway. The data was analysed using systematic text condensation. We found that the nurses reported mostly advantages, but also some disadvantages regarding accuracy, consistency, availability and efficiency in the medication information process when they used standardised electronic messages. Efforts to refine the electronic messages to achieve better work processes and patient safety should be addressed.

Introduction

The lack or failure of transmission of patient information between agencies in health care can lead to serious errors in the continuity of patient care, improper treatment and possible injuries to the patient, or even death (1, 2). Mainly research has been conducted on interaction between hospitals and homecare, especially at the discharge process (3), with little consideration for the interaction between home care and GPs. The few studies conducted have shown that the flow of information between home care nurses and GPs is insufficient to ensure the proper quality of treatment and care (4). Communication is often informal and unsystematic, and nurses in home care may not receive accurate information when needed from either GPs or hospitals. In addition, nurses do not see it as their job to inform the GPs when a patient is discharged from the hospital (3). There are also several studies that describe the differences between home care and GP’s medication lists, as well as omissions and errors in medication information processes (4, 5). One of the reasons for this is that home care and GPs use different electronic health record systems (EPR), and these systems do not communicate with each other.

Many patients living at home need help from home care nurses to organize and administer their medication. The medication process can be divided in five steps: 1) prescribing, 2) dispensing, 3) administering, 4) monitoring and 5) systems and management control (6). Nurses and GPs have different tasks and responsibilities in this process. It is particularly in the first step when the doctor has prescribed a drug, in the fourth step when the nurses are monitoring and observing the effect of the drug, and in the fifth step when reviewing the complete drug regimen that there is a need for collaboration between the nurses in home care and the GPs. One of the big problems is that the collaborating and communicating are seldom documented, as it mostly takes place by telephone (7).

There is an assumption that being able to use standardised electronic interaction will lead to fewer mistakes and less unforeseen events, thereby allowing health care personnel to use more of their time on patients, and increasing patient safety (1). A newly launched coordination reform in Norway suggest that the municipalities should take over more of the responsibility for treatment and care from hospitals (8). This means increased treatment and care at home, which indicates a need for better and closer cooperation and communication between home care and GPs. To secure smooth transitions between the different levels of care, the Norwegian authorities have extended the implementation and use of electronic communication and information exchange to also include home care and nursing homes (9).

Until recently, there have not been any electronic information exchange solutions between home care and GPs in Norway. In 2005, the Norwegian Nurses Organisation initiated a project to standardise electronic information exchange between home care, nursing homes, hospitals and GPs. This involved a set of standardised electronic messages (e-messages) in which a specific message was aimed at exchanging medication information. The content of the medication message consists of the following metadata: start date, stop date, medication name, form, strength, dosage, and prescriber’s name. The Anatomical Therapeutic Chemical (ATC) classification system for drugs is used. This information is generated from the medication module in the EPR-system in to the e-messages.

The messages were developed and implemented in all the major electronic patient record systems (EPR) provided in Norway, making it possible to communicate and send information between home care and GP’s EPR systems. E-messages are now being implemented in several municipalities and collaborating GP offices (10). Our research question for the current paper was to explore how home care nurses experienced the medication information processes when using standardised electronic messages in the communication with the GPs. The reason for exploring this is the expectation that implementing e-messages contribute to bridging the information gap between home care and GPs.

Method

We have used a combination of approaches to study nurses’ perspectives on the use of e-messages in their medication information processes with GPs. Two focus groups interviews with a total of six nurses, and semi-structured individual interviews with 12 nurses were conducted, all of whom worked in home care. They were employed in various units in two different municipalities. The inclusion criteria were that they had used e-messages for more than six months prior to their interviews. The study has been assessed by the Regional Committee for Medical and Health Research Ethics and by the Norwegian Social Science Data Services. All the participants have given their written informed consent.

The second author as an experienced researcher acted as moderator, and the first author was an assistant moderator during the interviews. The interview guide consisted of open questions in order to evoke conversation and reflection (11). Some of the themes related to what experiences they had with e-messages in terms of how and what type of information they exchanged and in what type of situations they used e-messages. The focus group interviews lasted from 80 to 90 minutes, while the individual interviews lasted from 30 to 45 minutes.

The interviews were transcribed verbatim by the first author and a research assistant. We started the analysis by looking at how the themes from the interview guide had been answered and discussed. We then decided to isolate the themes and created a matrix with underlying subthemes. Next, we analysed the text by using systematic text condensation (12), which involved a four-step process: 1) obtaining an overall impression, 2) identifying meaningful units, 3) abstracting the content of the meaningful units, and 4) summarizing the importance of these steps. We have applied Actor Network Theory with its emphasis on a heterogeneous network of actors and technology, namely actants, that interact and affect each other as a backdrop for analysing and interpreting the data (13). The theory and its key concepts of translation, inscription and alignment all contributed to shedding light on how electronic exchange of information can lead to changes in practice or not, in this case, the medication information practices between home care and GPs. In the present paper, inscription is highlighted as a way of better understanding the complexity of this field.

Results

An overall finding was the nurses’ concerns about the quality of the information exchanged in the medication process between GPs and home care. Three themes appeared to be of importance: 1) the accuracy and consistency of the medication lists, 2) the availability of the medication information, and 3) the efficiency of the medication information processes. In all of these areas, the nurses had different experiences. In the following, we will present both the advantages and disadvantages they experienced with e-messages.

Accuracy and consistency of medication lists

The nurses had different experiences with the accuracy and consistency in the content of the e-messages. Some reported that the content in the medication list was more accurate and correct now than before they started using e-messages. As one nurse said: “I feel that the patient’s medication lists are more correct ……..it is somehow easier to get updated.” The medication message is now automatically generated from both the nurses’ and GPs’ EPR. Previously, they could not generate and exchange the information electronically, and had to write up the medication information in a paper-based list and exchange it by mail, fax or telephone.

However, the consistency of the electronic medication message depends on whether the GPs have updated their medication lists in their EPR system or not. Several nurses had experienced that they often received incorrect medication messages from the GPs.

Nurse 1: I automatically check through the medication message that the GP has sent us and it is ... not updated at least for 50% of the time in relation to what we have so I make a phone call and ask ... “the last time she was not on this drug. Is she going to have it now? The medicine message you sent now is different from what we got 14 days ago.” So I think it’s working poorly, I get confused.

Nurse 2: I've often found that the doctor writes “Yes, that's right that he should have so and so”, and then he sends the medication message, but he has not corrected it. That has happened many times.

The nurses went on to tell that some GPs had expressed that they themselves had a job to do in order to update the medication lists in their EPRs to avoid reusing incorrect information.

Availability to medication information

Despite the above described problems, nurses were very pleased with having the opportunity to use e-messages because the medication information were more available and assessed as being more trustworthy. The reason for this was that previously the nurses did not receive the medication information in written form from the GPs.

And another thing ... that is, when it comes to medication information, so today we get that in writing. Written changes, we didn’t get that before.

The collaboration and communication about the medication is documented both in EPRs for home care and the GPs’ offices. Because it is electronic, it is available for everybody involved in the care of the patient.

Nurse 1: It's a great way to communicate. You have it in writing, in both records verbatim. So you have documentation that you have actually been in contact with the GP…… Also, you have documented what you have done. It is very good.

Nurse 2: ... Because you get the whole dialogue in the EPR ... So if everything is written, concrete and simple, so .. it is easy to find out things

This demonstrates that the nurses experience that the medication information is available if the EPR is written and accurate.

Efficiency in the medication information process

Previously, the nurses had to adjust their communication and information exchange to specific times when they could actually talk to each other, which was not always suitable in their work routines. They used a lot of time to come in contact with the GPs, which is time that may have been used for direct patient care. The consequence of having the e-messages available compared to earlier practices was that new patient treatments could start without delay as long as the GP immediately sends medication changes via e-message to the nurses in home care.

…when a patient has had a doctor's appointment, the doctor can give feedback to us that now the patient will start on a new medicine and we can get it at the pharmacy and give it right away. ….. So it's very nice.

In addition, the nurses were also notified about follow-ups and that the GP would evaluate the treatment as shown in the example below.

So if a patient has started a new medicine, then the GP sends an e-message to tell us that the patient has a new appointment then and there. And then I know that they will return to the GP and the medication will be reconsidered. It is nice.

Producing an e-message fits their work processes better than before. One nurse talked about how she and the GP wrote a message when it was most convenient.

You can write a message just when it suits you and the GP can answer when it suits him or her. So my experience is that you actually receive or send information to the GP that you might not receive or send in the next 3 – 4 days because you either did not get through on the telephone, or you have forgotten it, or that you weren’t at work and nobody else followed it up.

The nurses said it took less time to contact the GP now than before they used e-messages. Previously, they had to telephone or visit the GP’s office in order to communicate with them.

We often have to sit in a telephone queue. It takes normally 10 – 15 minutes. …… It takes 2 minutes to write an e-message, but if we are to sit in a queue for a quarter…., we do not have time for that in home care.”

Despite the enthusiasm about e-messages, the nurses felt that improvements should be made. For example, they experienced that e-messages were not developed for all purposes. The nurses missed the opportunity to comment on prescribed medicines on the medication messages.

I think the e-messages are fine, but I miss the comments in the medication list. It is the only thing I have experienced as being weak so far.”

Yes, short comments, does this match with what you have on your list, you know. Now they have been so many times in the hospital for example.

The general consensus was that they thought that they may have saved time if commenting was an option.

Discussion

In this study, we aimed to investigate nurses’ perspectives on using e-messages in their medication information practices with GPs. The overall finding was that the nurses were satisfied with the opportunity to use e-messages in the medication process if they compared it to not having it. An accurate and easy available medication list would probably generate fewer errors in the medication information process (14). Even so, our findings revealed that there are still improvements to be made in order to avoid errors and enhance patient safety. Further, we will discuss the advantages and disadvantages with e-messages.

The most obvious advantages for the nurses were that they received medication information in writing and that they could reuse the medication information from their EPRs in e-messages when sending them. There is always a risk that errors will occur when information is transferred manually (15). There are studies which show that the use of technology leads to fewer errors in the process of transmitting medication information (15). Before the introduction of e-messages, the telephone was the most important tool for collecting and exchanging information, with the inherent implications in this being the unnecessary use of time and the possibility of misunderstandings and errors. Our findings also indicate that using e-messages improves efficiency for both patient treatment and the organisation of work. The nurses are satisfied that e-messages make it easier to contact GPs. They use less time, and the communication and information exchange with the GP can be adapted to their work routines. The communication is documented and easy for other nurses to access when needed. A study of nurses in municipalities who participated in a pilot project of communicating electronically with hospitals showed less informal communication and use of the telephone (16), which is supported by the results of this study. The fact that they are using the e-messages is an example of strong inscription in the solution (13).

Among the disadvantages we found was that electronically receiving the medication lists from GPs was not “equivalent” with receiving correct or up-to-date information. This is similar to findings from other studies (4, 17–19). Implementing e-messages may create a potential risk for unintended events and new errors in the medication information process. Studies in related areas have also demonstrated the same consequences when new technology has been implemented (19–21). Another unintended result is the production of new work for the nurses because of sending the medication lists back to the GP in order to have them corrected. The inconsistencies in the medication lists from the GPs may reduce trust in the information they receive, thus possibly leading to less use of e-messages. So far this has not occurred, and another study of the implementation of multidose drug dispensing systems showed that even if the new system caused new errors and new working routines, there was still trust in the system (19). The nurses’ dissatisfaction with the inability to comment on the medication list may also create workarounds and “blocks in workflow” in the medication information exchange process (22), and may be an expression of what ANT refers to as weak inscription (13).

Conclusion

This study has shown that there are both advantages and disadvantages with e-messages in the medication information process between nurses in home care and GPs. E-messages are flexible, the communication and information exchange is getting documented and becoming available, it is less time consuming and it may lead to a quicker initiation of patient treatment. On the other hand, there are improvements to be made in regard to updating the medication lists in the EPR, in addition to the possibility of commenting on the medication information in the e-messages. This would lead to even less time used, better trust in the information and less risk of errors and unintended events.

According to ANT, the technology is one important factor; other important factors are the organizational and systems-related conditions. In the understanding of the introduction and use of technology, this cannot be viewed independently. The present study shows that not all of these factors were taken into account, and that further investigations should address these issues.