Preparing community pharmacy teams for health information exchange (HIE).

BACKGROUND: Health information exchanges (HIEs) facilitate health care professionals' electronic sharing of patient information across different organizations. When community pharmacists have access to HIE, they can further contribute to improved patient outcomes. However, several implementation challenges are noted, which impede sustained pharmacist access to HIE. To our knowledge, no bidirectional HIE interface design and pharmacy team-informed implementation process has been documented. In response, our research team designed and developed an HIE interface prototype for use specifically by community pharmacy teams to access local HIE data through their pharmacy dispensing software. OBJECTIVES: To 1) identify barriers, facilitators, and recommendations for using HIE data in community pharmacies and 2) create a curated list of resources addressing identified implementation needs to aid future implementation of a fully functional, bidirectional HIE interface by community pharmacy teams. METHODS: Pharmacists, pharmacy technicians, and patients from three pharmacy sites within the Community Pharmacy Enhanced Services Network of Indiana participated in individual semi-structured interviews. Interview questions were mapped to select constructs across all domains of the Consolidated Framework for Implementation Research. Interview transcripts were deductively coded. A subset of participants participated in Evidence-Based Quality Improvement sessions to iteratively update planned resource items needed to support future HIE implementation. RESULTS: We interviewed 23 total participants: 8 pharmacists, 8 pharmacy technicians, and 7 patients. Five facilitators, four barriers, and two recommendations were identified. These were further characterized into four key implementation needs: instruction on how to use HIE; guidance on workflow and team roles; resources that are patient-facing; and resources that are provider-facing, resulting in 16 planned implementation resources. CONCLUSION: Our study provides the first-of-its-kind list of pharmacy team-informed resources to facilitate sustainability and scalability of HIE implementation in community pharmacies.

Cognitive task analysis of clinicians' drug-drug interaction management during patient care and implications for alert design.

BACKGROUND: Drug-drug interactions (DDIs) are common and can result in patient harm. Electronic health records warn clinicians about DDIs via alerts, but the clinical decision support they provide is inadequate. Little is known about clinicians' real-world DDI decision-making process to inform more effective alerts. OBJECTIVE: Apply cognitive task analysis techniques to determine informational cues used by clinicians to manage DDIs and identify opportunities to improve alerts. DESIGN: Clinicians submitted incident forms involving DDIs, which were eligible for inclusion if there was potential for serious patient harm. For selected incidents, we met with the clinician for a 60 min interview. Each interview transcript was analysed to identify decision requirements and delineate clinicians' decision-making process. We then performed an inductive, qualitative analysis across incidents. SETTING: Inpatient and outpatient care at a major, tertiary Veterans Affairs medical centre. PARTICIPANTS: Physicians, pharmacists and nurse practitioners. OUTCOMES: Themes to identify informational cues that clinicians used to manage DDIs. RESULTS: We conducted qualitative analyses of 20 incidents. Data informed a descriptive model of clinicians' decision-making process, consisting of four main steps: (1) detect a potential DDI; (2) DDI problem-solving, sensemaking and planning; (3) prescribing decision and (4) resolving actions. Within steps (1) and (2), we identified 19 information cues that clinicians used to manage DDIs for patients. These cues informed their subsequent decisions in steps (3) and (4). Our findings inform DDI alert recommendations to improve clinicians' decision-making efficiency, confidence and effectiveness. CONCLUSIONS: Our study provides three key contributions. Our study is the first to present an illustrative model of clinicians' real-world decision making for managing DDIs. Second, our findings add to scientific knowledge by identifying 19 cognitive cues that clinicians rely on for DDI management in clinical practice. Third, our results provide essential, foundational knowledge to inform more robust DDI clinical decision support in the future.

Usability Evaluation of a Community Pharmacy Health Information Exchange Interface Prototype.

OBJECTIVE: Few community pharmacies have access to health information exchange (HIE) data. We conducted a first-of-its-kind usability evaluation of an HIE interface prototype (referred to throughout as the "HIE-Pioneer mock-up") developed with pharmacists and pharmacy technicians to aid future implementation in community pharmacies. METHODS: Community pharmacists and pharmacy technicians were recruited to complete usability evaluations with the HIE-Pioneer mock-up. Each usability evaluation lasted up to 60 minutes. System usability scale (SUS) scores were collected from each participant following each usability evaluation session and summarized with descriptive statistics. Usability evaluation videos were reviewed for common usability attributes, such as the impact of identified usability problems, learnability, and efficiency. Time on task, task success rates, and prototype utilization were also recorded. RESULTS: Sixteen total participants completed usability testing across three community pharmacies. The average SUS score was 69.7 (scale 0-100, where 100 is the best), with pharmacists on average reporting higher satisfaction than technicians (74.1 vs. 65.3, respectively). Altogether, we identified 23 distinct usability problems. Key problems identified included needed clarification in tool label names and accessibility of HIE links within the existing workflow. Overall, the usability of the HIE-Pioneer mock-up generally fostered pharmacy professionals' ease of learning and efficiency. CONCLUSION: Our study identified key areas, and potential solutions, to improve the usability of the HIE-Pioneer mock-up. Overall, pharmacy professionals viewed the HIE-Pioneer mock-up positively, with good satisfaction ratings. The HIE-Pioneer mock-up provides a blueprint for future HIE implementation in community pharmacy settings, which would increase community pharmacy teams' access to HIE data nationwide. Community pharmacy access to bi-directional HIE is expected to improve communication among more health care professionals involved in patient care and equip pharmacy professionals with needed information for improved clinical decision-making.

Maximizing student potential: Lessons for pharmacy programs from the patient safety movement.

Higher education institutions (HEIs), including pharmacy programs, are experiencing growing pressure from the public and policy makers to develop student-centered learning experiences that meet societal needs. While HEIs may have in-house initiatives to meet such challenges, there are also opportunities for cross-domain learning and application of useful concepts from other sectors. One such sector that lends itself to cross-domain learning is the healthcare industry. Like HEIs, the healthcare industry has been experiencing pressure from its stakeholders, in this case, to address patient safety gaps. These forces intensified at the turn of the century leading to the emergence of what is now known as the patient safety movement, which enabled increased advocacy, education, and research to reduce healthcare-related harm. Despite persistent challenges, a key achievement of the patient safety movement has been application of a systems framework to understand and solve patient safety gaps. That is, patient safety gaps are often a result of system defects rather than isolated acts of individual workers operating in a complex social and technical work setting (often referred to as sociotechnical system). Commonly used systems frameworks describe a sociotechnical system through its components: 1) structure (e.g., people, tools/technology, physical workspaces); 2) processes (e.g., medication administration); and 3) outcomes (e.g., medication safety, patient satisfaction). At their core, both HEIs and healthcare organizations are complex sociotechnical systems that organize their structures to support specific processes - learning in HEIs and patient safety in healthcare - to ultimately improve outcomes for students and patients, respectively. This paper describes parallels between HEIs and the healthcare domain to illustrate how patient safety concepts and practices from healthcare can be adapted to HEIs in order to enhance educational structures, processes, and learning outcomes.

The Perceived Effectiveness of Secure Messaging for Medication Reconciliation During Transitions of Care: Semistructured Interviews With Patients.

BACKGROUND: Medication discrepancies can lead to adverse drug events and patient harm. Medication reconciliation is a process intended to reduce medication discrepancies. We developed a Secure Messaging for Medication Reconciliation Tool (SMMRT), integrated into a web-based patient portal, to identify and reconcile medication discrepancies during transitions from hospital to home. OBJECTIVE: We aimed to characterize patients' perceptions of the ease of use and effectiveness of SMMRT. METHODS: We recruited 20 participants for semistructured interviews from a sample of patients who had participated in a randomized controlled trial of SMMRT. Interview transcripts were transcribed and then qualitatively analyzed to identify emergent themes. RESULTS: Although most patients found SMMRT easy to view at home, many patients struggled to return SMMRT through secure messaging to clinicians due to technology-related barriers. Patients who did use SMMRT indicated that it was time-saving and liked that they could review it at their own pace and in the comfort of their own home. Patients reported SMMRT was effective at clarifying issues related to medication directions or dosages and that SMMRT helped remove medications erroneously listed as active in the patient's electronic health record. CONCLUSIONS: Patients viewed SMMRT utilization as a positive experience and endorsed future use of the tool. Veterans reported SMMRT is an effective tool to aid patients with medication reconciliation. Adoption of SMMRT into regular clinical practice could reduce medication discrepancies while increasing accessibility for patients to help manage their medications. TRIAL REGISTRATION: ClinicalTrials.gov NCT02482025; https://clinicaltrials.gov/ct2/show/NCT02482025.

Strategies prescribers and pharmacists use to identify and mitigate adverse drug reactions in inpatient and outpatient care: a cognitive task analysis at a US Veterans Affairs Medical Center.

OBJECTIVE: To develop a descriptive model of the cognitive processes used to identify and resolve adverse drug reactions (ADRs) from the perspective of healthcare providers in order to inform future informatics efforts SETTING: Inpatient and outpatient care at a tertiary care US Veterans Affairs Medical Center. PARTICIPANTS: Physicians, nurse practitioners and pharmacists who report ADRs. OUTCOMES: Descriptive model and emerging themes from interviews. RESULTS: We conducted critical decision method interviews with 10 physicians and 10 pharmacists. No nurse practitioners submitted ADR incidents. We generated a descriptive model of an ADR decision-making process and analysed emerging themes, categorised into four stages: detection of potential ADR, investigation of the problem's cause, risk/benefit consideration, and plan, action and follow-up. Healthcare professionals (HCPs) relied on several confirmatory or disconfirmatory cues to detect and investigate potential ADRs. Evaluating risks and benefits of related medications played an essential role in HCPs' pursuits of solutions CONCLUSIONS: This study provides an illustrative model of how HCPs detect problems and make decisions regarding ADRs. The design of supporting technology for potential ADR problems should align with HCPs' real-world cognitive strategies, to assist fully in detecting and preventing ADRs for patients.

A mixed-methods study of pharmacy instructors' early experiences with a teaching electronic medical record.

INTRODUCTION: As use of electronic medical records (EMRs) increases in healthcare, multiple accreditation organizations recommend training future clinicians on EMRs as part of the academic curriculum. Therefore, some pharmacy programs now utilize an academic EMR. Our objective was to examine pharmacy instructors' early experiences with a commercially available teaching EMR (tEMR) in order to identify current and future priorities along with benefits and barriers to academic EMR use in pharmacy education. METHODS: We conducted semi-structured interviews and a web-based survey with pharmacy instructors. Interview and survey data analyses consisted of hybrid inductive/deductive approaches to coding data and descriptive statistics, respectively. We mapped themes to the Pharmacists' Patient Care Process (PPCP). RESULTS: Seven instructors participated in interviews, and 10 completed the survey. We identified 25 interview themes that were generally congruent with survey responses. A noted benefit of the tEMR was providing a large repository of real-life patient data. Instructors' current priorities for tEMR activities primarily aligned with "collect," "assess," and "plan" steps of the PPCP. One reported barrier was insufficient training regarding the tEMR capabilities. Instructors offered innovative ideas for future academic EMR use, including pharmacokinetics, incident reporting, and longitudinal cases. CONCLUSIONS: Study findings are most applicable to pharmacy programs in the early stages of academic EMR adoption. We identified opportunities for pharmacy programs to facilitate innovative, future use of academic EMRs, including curriculum planning, so pharmacy students gain experience using EMR functions for each PPCP step and develop more advanced EMR skills.

Human factors and ergonomics methods for pharmacy research and clinical practice.

BACKGROUND: Human factors and ergonomics (HFE) is a scientific and practical human-centered discipline that studies and improves human performance in sociotechnical systems. HFE in pharmacy promotes the human-centered design of systems to support individuals and teams performing medication-related work. OBJECTIVE: To review select HFE methods well suited to address pharmacy challenges, with examples of their application in pharmacy. METHODS: We define the scope of HFE methods in pharmacy as applications to pharmacy settings, such as inpatient or community pharmacies, as well as medication-related phenomena such as medication safety, adherence, or deprescribing. We identify and present seven categories of HFE methods suited to widespread use for pharmacy research and clinical practice. RESULTS: Categories of HFE methods applicable to pharmacy include work system analysis; task analysis; workload assessment; medication safety and error analysis; user-centered and participatory design; usability evaluation; and physical ergonomics. HFE methods are used in three broad phases of human-centered design and evaluation: study; design; and evaluation. The most robust applications of HFE methods involve the combination of HFE methods across all three phases. Two cases illustrate such a comprehensive application of HFE: one case of medication package, label, and information design and a second case of human-centered design of a digital decision aid for medication safety. CONCLUSIONS: Pharmacy, including the places where pharmacy professionals work and the multistep process of medication use across people and settings, can benefit from HFE. This is because pharmacy is a human-centered sociotechnical system with an existing tradition of studying and analyzing the present state, designing solutions to problems, and evaluating those solutions in laboratory or practice settings. We conclude by addressing common concerns about the implementation of HFE methods and urge the adoption of HFE methods in pharmacy.

Organizational conditions that influence work engagement and burnout: A qualitative study of mental health workers.

Objective: Clinician burnout in healthcare is extensive and of growing concern. In mental health and rehabilitation settings, research on interventions to improve burnout and work engagement is limited and rarely addresses organizational drivers of burnout. This study sought to elaborate on the organizational influence of burnout and work engagement in mental health. Methods: We randomly selected 40 mental health clinicians and managers who were participating in a burnout intervention and conducted semi-structured interviews to understand their views of organizational conditions impacting burnout and work engagement. Data were analyzed using a thematic analytical approach. Results: Analyses yielded three major themes where organizational contexts might reduce burnout and increase work engagement: (a) a work culture that prioritizes person-centered care over productivity and other performance metrics, (b) robust management skills and practices to overcome bureaucracy, and (c) opportunities for employee professional development and self-care. Participants also referenced three levels of the organizational context that they believed influenced burnout and work engagement: front-line supervisors and program managers, organizational executive leadership, and the larger health system. Conclusions and Implications for Practice: Findings point to several possible targets of intervention at various organizational levels that could guide the field toward more effective ways to reduce burnout and improve work engagement. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Care Coordination Strategies and Barriers during Medication Safety Incidents: a Qualitative, Cognitive Task Analysis.

BACKGROUND: Medication errors are prevalent in healthcare institutions worldwide, often arising from difficulties in care coordination among primary care providers, specialists, and pharmacists. Greater knowledge about care coordination surrounding medication safety incidents can inform efforts to improve patient safety. OBJECTIVES: To identify strategies that hospital and outpatient healthcare professionals (HCPs) use, and barriers encountered, when they coordinate care during a medication safety incident involving an adverse drug reaction, drug-drug interaction, or drug-renal concern. DESIGN: We asked HCPs to complete a form whenever they encountered these incidents and intervened to prevent or mitigate patient harm. We stratified incidents across HCP roles and incident categories to conduct follow-up cognitive task analysis interviews with HCPs. PARTICIPANTS: We invited all physicians and pharmacists working in inpatient or outpatient care at a tertiary Veterans Affairs Medical Center. We examined 24 incidents: 12 from physicians and 12 from pharmacists, with a total of 8 incidents per category. APPROACH: Interviews were transcribed and analyzed via a two-stage inductive, qualitative analysis. In stage 1, we analyzed each incident to identify decision requirements. In stage 2, we analyzed results across incidents to identify emergent themes. KEY RESULTS: Most incidents (19, 79%) were from outpatient care. HCPs relied on four main strategies to coordinate care: cognitive decentering; collaborative decision-making; back-up behaviors; and contingency planning. HCPs encountered four main barriers: role ambiguity and constraints, breakdowns (e.g., delays) in care, challenges related to the electronic health record, and factors that increased coordination complexity. Each strategy and barrier occurred across all incident categories and HCP groups. Pharmacists went to extra effort to ensure safety plans were implemented. CONCLUSIONS: Similar strategies and barriers were evident across HCP groups and incident types. Strategies for enhancing patient safety may be strengthened by deliberate organizational support. Some barriers could be addressed by improving work systems.

A user-centered evaluation of medication therapy management alerts for community pharmacists: Recommendations to improve usability and usefulness.

BACKGROUND: Community pharmacists provide comprehensive medication reviews (CMRs) through pharmacy contracts with medication therapy management (MTM) vendors. These CMRs are documented in the vendors' web-based MTM software platforms, which often integrate alerts to assist pharmacists in the detection of medication therapy problems. Understanding pharmacists' experiences with MTM alerts is critical to optimizing alert design for patient care. OBJECTIVES: The objectives of this study were to 1) assess the usability and usefulness of MTM alerts for MTM vendor-contracted community pharmacists and 2) generate recommendations for improving MTM alerts for use by community pharmacists. METHODS: This was a convergent, parallel mixed-methods evaluation of data collected from 3 sources, with individual pharmacists contributing data to one or more sources: 1) community pharmacists' submissions of observational data about MTM alerts encountered during routine MTM provision, 2) videos of naturalistic usability testing of MTM alerts, and 3) semi-structured interviews to elicit pharmacists' perspectives on MTM alert usefulness and usability. MTM alert data submitted by pharmacists were summarized with descriptive statistics. Usability testing videos were analyzed to determine pharmacists' time spent on MTM alerts and to identify negative usability incidents. Interview transcripts were analyzed using a hybrid approach of deductive and inductive codes to identify emergent themes. Triangulation of data (i.e., determination of convergence/divergence in findings across all data sources) occurred through investigator discussion and identified overarching findings pertaining to key MTM alert challenges. These resulted in actionable recommendations to improve MTM alerts for use by community pharmacists. RESULTS: Collectively, two and four overarching key challenges pertaining to MTM alert usability and usefulness, respectively, were identified, resulting in 15 actionable recommendations for improving the design of MTM alerts from a user-centered perspective. CONCLUSIONS: Recommendations are expected to inform enhanced MTM alert designs that can improve pharmacist efficiency, patient and prescriber satisfaction with MTM, and patient outcomes.

Pharmacy students' perspectives on the initial implementation of a teaching electronic medical record: results from a mixed-methods assessment.

BACKGROUND: Electronic medical records (EMRs) have been used for nearly three decades. Pharmacists use EMRs on a daily basis, but EMRs have only recently been incorporated into pharmacy education. Some pharmacy programs have implemented teaching electronic medical records (tEMRs), but best practices for incorporating tEMRs into pharmacy education remain unknown. The objectives of this study were to 1) assess pharmacy students' views and experiences with a tEMR; and 2) identify current learning activities and future priorities for tEMR use in pharmacy education. METHODS: We used a mixed-methods approach, including three, two-hour student focus groups and a 42-item web-based survey to examine student perspectives of the tEMR. All first, second, and third year professional pharmacy students were eligible to participate in the survey and a focus group. Web-based survey items were measured on a 7-point Likert scale, and quantitative analyses included descriptive statistics. Two researchers independently coded transcripts using both deductive and inductive approaches to identify emergent themes. These analysts met and resolved any coding discrepancies via consensus. RESULTS: Focus groups were conducted with 22 total students, with 6-8 students represented from each year of pharmacy training. The survey was completed by 156 students: 47 first year, 55 second year, and 54 third year. Overall, 48.7% of survey respondents altogether agreed or strongly agreed that using the tEMR enhanced their learning in pharmacy classes and laboratories. Qualitative data were organized into four major themes regarding tEMR adoption: current priorities for use within the pharmacy curriculum; tEMR benefits; tEMR barriers; and future priorities for tEMR use to prepare students for pharmacy practice. CONCLUSIONS: This study reveals pharmacy students' perspectives and attitudes towards using a tEMR, the types of classroom activities that incorporate the tEMR, and students' future suggestions to enhance the design or application of the tEMR for their learning. Our research findings may aid other pharmacy programs and promote more effective use of tEMRs in pharmacy education. In the long-term, this study may strengthen pharmacy education on EMRs and thus increase the efficacy and safety of pharmacists' EMR use for patients' medication management.

Community pharmacists' and residents' decision making and unmet information needs when completing comprehensive medication reviews.

OBJECTIVE: To (1) characterize community pharmacists' and community pharmacy residents' decision making and unmet information needs when conducting comprehensive medication reviews (CMRs) as part of medication therapy management and (2) explore any differences between community pharmacists and community pharmacy residents in CMR decision making and unmet information needs. DESIGN: Thirty-to 60-minute semistructured interviews framed using a clinical decision-making model (CDMM) were conducted with community pharmacists and residents. SETTING AND PARTICIPANTS: Participants were recruited from practice-based research networks and researchers' professional networks. Eligible participants had completed or supported the completion of at least 2 CMRs in the last 30 days. OUTCOME MEASURES: Two researchers independently coded transcripts using a combination of inductive and deductive methods to identify themes pertaining to community pharmacists' and residents' decision making and unmet information needs in the provision of CMRs. Discrepancies among researchers' initial coding decisions were resolved through discussion. RESULTS: Sixteen participants (8 pharmacists and 8 residents) were interviewed. Themes were mapped to 5 CDMM steps. Participants primarily used subjective information during "case familiarization"; objective information was secondary. Information used for "generating initial hypotheses" varied by medication therapy problem (MTP) type. During "case assessment," if information was not readily available, participants sought information from patients. Thus, patients' levels of self-management and health literacy influenced participants' ability to identify and resolve MTPs, as described under "identifying final hypotheses." Finally, participants described "decision-making barriers," including communication with prescribers to resolve MTPs. Although pharmacist and resident participants varied in the types of MTPs identified, both groups cited the use and need of similar information. CONCLUSION: Community pharmacists and residents often rely primarily on patient-provided information for decision making during CMRs because of unmet information needs, specifically, objective information. Moreover, confidence in MTP identification and resolution is reduced by communication challenges with prescribers and limitations in patients' ability to convey accurate and necessary information.