Can Electronic Medical Records Help Improve Patients' Understanding of Medications?

Abstract

Objective

This study presents pilot data from an on-going electronic health record (EHR) quality improvement study to improve medication management with 1) a patient pre-visit review of their EHR medication list; 2) a plain language new medication information sheet to provide with every new EHR prescription. Findings describe the extent of medication discrepancies and perceived problems, concerns and questions (PCQs) about current medications and patient knowledge about new medications.

Study Design

Post-visit survey with 191 patients at an academic general internal medicine clinic.

Methods

Patients were asked about discrepancies and PCQs in their EHR summary for up to 10 current medications and about knowledge about new prescriptions.

Results

Overall, 78% of patients had at least one discrepancy, over half had either a drug listed they were not taking or dose or frequency discrepancies and about 9% reported an omission; 42% indicated at least one PCQs about their current medications. Among patients who received a new prescription, not knowing what the new medication was for or how to take it was rare. However, 66% indicated uncertainty about potential side effects that they should ‘call the doctor about’.

Conclusions

Lessons learned for our current study include 1) discrepancies can be efficiently categorized by pre-visit review of EHR medication lists; 2) pre-review offers physicians the opportunity to better address important medication PCQs; 3) testing the value of EMR-generated plain language medication information sheets requires follow-up interviews after medications are filled; 4) patients may not understand the actual benefits of new medications.

Over a decade of experience with our General Internal Medicine Clinic Electronic Medical Record (EPIC, Madison WI) has shown that the EMR provides clinicians with more efficient documentation, more rapid and timely access to tests and procedure findings, and useful preventive services alerts for patients.^1-2 However, we have also found that the attention required to enter and access EMR information in the exam room can potentially detract from the quality of interpersonal communication with patient.³ Physicians may avoid the time required to clean up and update EMR medication screens during a particular visit, old prescriptions are left on lists, drugs which were prescribed by other medical specialists or alternative providers are not entered, and newly ordered prescriptions may be hastily discussed with patients.^4,5

The advent of the electronic medical record (EMR) offers the potential for primary care practices to adopt new approaches to eliminating medication discrepancies, while also providing patients with easy to understand instructions about new prescriptions that will enhance medication safety and adherence. The Northwestern General Internal Medicine clinic in downtown Chicago was recently awarded a grant from the Agency for Healthcare Research and Quality (AHRQ) to design an EMR-based physician randomized trial to simultaneously improve medication reconciliation and communication about new medications.

Because the EMR is in use during each patient visit, it is possible to easily review current medication lists. To aid in this process, our intervention includes a new step in our rooming process which enlists patients’ help in flagging potential discrepancies. Patients receive an EMR medication list of their current medications at check in, allowing them to review any discrepancies before their physician visit. In addition, to improve patient understanding of their new medications, we have created plain-language medication information sheets that have been populated in the EMR to be printed out for patients when they are prescribed a new medication.

To help shape this intervention, we conducted post-visit, in-person patient interviews to evaluate 1) the extent of medication discrepancies, 2) perceived problems, concerns and questions (PCQs) about current medications, and 3) patient knowledge about new prescriptions, including what the newly prescribed medication was for, how and when to take it, and potential side effects. The results of this baseline study are being used to guide our planned EMR-based intervention.

Methods

Patient Sample

For our baseline feasibility study, we decided to enroll a convenience sample of approximately 200 patients, 21 years or older and fluent in English. Upon completion of the interview, participants were given $10. The Northwestern University Institutional Review Board approved the study.

Interview Protocol: Current Medications

Each month, physicians were sent a list of scheduled patients and asked to give permission for patients to receive a mailing regarding the study interview. Immediately after a scheduled patient visit check-out, patients were approached by a trained study research assistant (RA) to assess interest and obtain consent. Participants were asked if their physician had reviewed their current medications with them during that day's visit. Participants were then asked to go over their post-visit summary report, which is routinely printed directly from the EMR and given to them at check out. The post-visit summary contains a list of their current and any new medications prescribed at that visit and includes all prescriptions from our large multi-specialty practice. The RA then went through up to 10 previously existing prescriptions on their medication list summary. The RA asked participants if they were taking any medications that were not on the post-visit summary list. For this report, we only describe discrepancies with prescription medications.

For each of their current medications that they were actually taking, the RA then asked the participant: 1) Are you still taking it? 2) Are you taking it the way listed here? and 3) Do you have ‘any problems, concerns or questions’ (PCQs) about the medications, and what those PCQs were. Participants were asked if they wanted their physician or nurse to contact them about any reported PCQs. We describe the proportion of patients with commission discrepancies (not taking a listed medication), omission discrepancies (taking an unlisted medication) or dose or frequency discrepancies (not taking a listed medication as prescribed) or an overall discrepancy rate for each patient based on any of these three categories.

Interview Questions: New Medications

Patients who were prescribed a new medication during their visit were asked to rate their degree of uncertainty about each new prescription. Patients were asked 1) Do you know what your doctor prescribed the medication for? 2) Do you know how to use or take it? 3) Do you know if there are any side effects that you should call your doctor about? Patients were also asked if they had any PCQs about the new prescription that they were not able to discuss with their doctor. The RA did not judge whether patient answers were correct, only whether the patient was confident that they understood their prescription. Patients were also asked how long they were supposed to take the new medication. However, because duration of use for ‘as needed’ or trial prescriptions is often uncertain, duration of use was not included in calculating the proportion of patients who indicated they fully understood their new prescriptions.

Results

A total of 116 patients refused participation before we reached our goal of interviewing 191 patients with current prescriptions. Among the 191 patients, 38.7% had at least 10 prescription medicines listed on their post-visit summary report; 77% had at least five medications listed while 23% had one to four prescriptions. Only 5% of patients reported that they had not discussed their medications with their doctor during the visit.

Current Medication Discrepancies and Problems, Concerns and Questions

Table 1 presents the proportion of patients with any medication discrepancies between their post-visit self-report and their EMR post-visit summary printout, summed across up to 10 current prescriptions. We present each discrepancy category by patient sociodemographic characteristics. Commission and dose or frequency discrepancies were reported by over half of all patients. (Indeed, about a quarter of all patients had more than one medication discrepancy in these categories, data not shown). About 9% of patients reported omission discrepancies (prescription medications being taken that did not appear on the post-visit summary). Combining these categories across all prescriptions resulted in a remarkable 78% of patients having at least one (‘any’) discrepancy. There were no significant differences in discrepancies by patient characteristics.

Table 1.

Medication Discrepancies by Patient Characteristics Post-visit Interviews with 191 General Internal Medicine Clinic Patients Reviewing up to 10 Prescription Medications

	% of Sample	% Not Taking Listed Rx (commission)	% Not Taking Rx as Listed (dose/frequency)	% Taking Unlisted Rx (omission)	% Any Discrepancy
Age
65 and older	42.9	50.0	53.7	2.4	75.6
64 and younger	57.1	52.3	56.9	13.8	79.8
Sex
Female	67.0	51.6	52.3	10.9	78.1
Male	33.0	50.8	61.9	4.8	77.8
Race/Ethnicity
African American	36.6	47.1	57.1	8.6	75.7
White/Other	63.4	53.7	54.5	9.1	79.3
Education
High School Grad/GED or less	17.8	52.9	58.8	2.9	82.4
Some College Education	35.1	43.3	50.7	10.4	73.1
College or Grad Degree	47.1	56.7	57.8	10.0	80.0
All participants	100.0	51.3	55.5	8.9	78.0

When asked whether they had any PCQs about any medication they were taking, 41.9% indicated at least one PCQ. While patients reported a variety of PCQs, the most frequent concerns were about whether medications were working, whether certain symptoms were potential side effects, when to stop taking a drug, and dosages. However, only 3% of patients indicated that they wanted to contact their physician about a particular PCQ.

Understanding of New Medications

A total of 48 patients (25.1%) of study patients received at least one new prescription at their study visit. Only one patient indicated that they did not know what the new medication was for. Only five patients expressed uncertainty about how to take their new medication. However, 35 patients (66%) indicated uncertainty about potential side effects that they should call the doctor about. However, only three patients (5.7%) indicated that they had PCQs that they were unable to discuss with the doctor.

Discussion

Approximately 4 out of 5 interviewed patients had some type of discrepancy with their EMR summary, nearly half of patients reported a PCQ with at least one existing medication, and two-thirds of patients receiving a new medication reported inadequate information, mainly about potentially harmful side effects that would merit calling their doctor about. A substantial proportion of discrepancies were the result of specialty medications that had not been entered or removed from medication lists. While patient PCQs were common, it was unclear to what extent these issues reflected poor communication with their primary care physician as opposed to inevitable concerns and ambiguity about medication safety and efficacy. Finally, patients’ failure to clearly understand the most important new medication side effects may have largely been a function of overly detailed warnings, such as those found on package inserts, as well as lack of physician time to fully address side effects and other issues at the time of a new prescription. ^6-10

Our EMR based Medication Communication Quality Improvement Effort

For physicians randomized to the intervention, an EMR medication list is automatically printed when a patient check ins for their physician visit with instructions for the patient to cross out any medications they are no longer taking or duplicates. Patients are also asked to identify any medications they are not taking as listed by the EMR printout. On the same printout, patient are asked to mark any concerns they have using boxes labeled side effects, cost, needing refills, or other concerns. There is also a space on the list for patients to add any medications they are taking that are not on the list, including any over-the-counter medications, vitamins, or supplements. These sheets are collected when patients are roomed and made available for review by their physician. Anecdotally, physicians have reported the sheets to be of great value in ‘cleaning up’ discrepancies. Our initial tracking of visit times finds no additional time for experimental as compared to usual care physicians, although it is unknown whether additional discussion of medications may be displacing time that would have been used for other patient concerns.

Improving Patient Knowledge about New Medications

Medication information sheets used in our study were created for the top 250 prescribed medications by the joint efforts of a communication specialist, a health literacy specialist, as well as pharmacists, physicians, and patients interviewed in focus groups. Each sheet is being formatted under eight headings: purpose, benefit, length of treatment, instructions, safe use, side effects and warnings, discussion points, and follow-up. These medication information sheets are automatically printed and given to patients along with each new prescription at check out by physicians randomized to our quality improvement intervention.

Other Lessons for Evaluating Medication Communication Quality Improvement

Studies have found that when prescribing a new medication, physicians most frequently mentioned product name and instructions for use; other topics such as risks and benefits were mentioned far less frequently.¹¹ In our pilot study, it was apparent that while patients knew what a medication was prescribed for, they had much less certainty about what to expect about the actual health benefits of their prescription. With the creation of the new medication information sheets, we hope to stress the importance and understanding of the benefits of the medications, in part to balance fears about the potential side effects listed. We also hope to emphasize the most common side effects and warnings that patients should call their physician about if they experience them, rather than relying on package insert warnings that often include a huge ‘laundry list’ of every reported side effect no matter how rare.

In order to obtain a more objective rating of patient knowledge about their new medications, our study now uses both post-visit interviews and telephone follow-up interviews that will take place after the patient has actually filled (or not filled) their prescription. Only by waiting until patients have filled their prescriptions can we assess understanding as correct or incorrect, and can get a better idea of how patients are actually taking their medications.

Conclusion

These pilot data were used to develop a better strategy to improve medication reconciliation and patient knowledge of medication regimes. By using the availability of real time review and access to educational materials afforded by the EMR, we hope to create a higher standard of care for primary care physicians that will not require significant additional time and effort over the long run. We are currently evaluated these changes to our process of care in a physician randomized trial. If proven successful, our approach has the potential for rapid adaptation and dissemination by any practice that uses the EMR.

Précis.

Patients' problems in understanding of new and existing medications were evaluated to design a primary care electronic health record quality improvement study.

Take-away points.

Medication discrepancies, patients’ perceived problems with current medications and understanding of new prescriptions were evaluated in a post-visit survey of 200 patients from an academic general internal medicine clinic.

• 78% of patients had at least one discrepancy.

• Almost half of patients had problems, concerns, and questions (PCQs) about their current medications.

• Two-third of patients were uncertain about potential side effects of newly prescribed medications.

• These results suggested the need for a patient pre-visit review of their EMR medication list and use of EMR plain language information about new prescriptions, including a description of medication benefits.