Patient Partnership Tools to Support Medication Safety in Community-Dwelling Older Adults: Protocol for a Nonrandomized Stepped Wedge Clinical Trial.

BACKGROUND: Preventable harms from medications are significant threats to patient safety in community settings, especially among ambulatory older adults on multiple prescription medications. Patients may partner with primary care professionals by taking on active roles in decisions, learning the basics of medication self-management, and working with community resources. OBJECTIVE: This study aims to assess the impact of a set of patient partnership tools that redesign primary care encounters to encourage and empower patients to make more effective use of those encounters to improve medication safety. METHODS: The study is a nonrandomized, cross-sectional stepped wedge cluster-controlled trial with 1 private family medicine clinic and 2 public safety-net primary care clinics each composing their own cluster. There are 2 intervention sequences with 1 cluster per sequence and 1 control sequence with 1 cluster. Cross-sectional surveys will be taken immediately at the conclusion of visits to the clinics during 6 time periods of 6 weeks each, with a transition period of no data collection during intervention implementation. The number of visits to be surveyed will vary by period and cluster. We plan to recruit patients and professionals for surveys during 405 visits. In the experimental periods, visits will be conducted with two partnership tools and associated clinic process changes: (1) a 1-page visit preparation guide given to relevant patients by clinic staff before seeing the provider, with the intention to improve communication and shared decision-making, and (2) a library of short educational videos that clinic staff encourage patients to watch on medication safety. In the control periods, visits will be conducted with usual care. The primary outcome will be patients' self-efficacy in medication use. The secondary outcomes are medication-related issues such as duplicate therapies identified by primary care providers and assessment of collaborative work during visits. RESULTS: The study was funded in September 2019. Data collection started in April 2023 and ended in December 2023. Data was collected for 405 primary care encounters during that period. As of February 15, 2024, initial descriptive statistics were calculated. Full data analysis is expected to be completed and published in the summer of 2024. CONCLUSIONS: This study will assess the impact of patient partnership tools and associated process changes in primary care on medication use self-efficacy and medication-related issues. The study is powered to identify types of patients who may benefit most from patient engagement tools in primary care visits. TRIAL REGISTRATION: ClinicalTrials.gov NCT05880368; https://clinicaltrials.gov/study/NCT05880368. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/57878.

Home medication inventory method to assess over-the-counter (OTC) medication possession and use: A pilot study on the feasibility of in-person and remote modalities with older adults.

BACKGROUND: There is a need for reproducible methods to measure over-the-counter (OTC) medication possession and use. This is because OTC medications are self-managed, variably monitored by healthcare professionals, and in certain populations such as older adults some OTC medications may introduce risk and cause more harm than benefit. OBJECTIVE: (s): To develop and assess the feasibility of the Home Medication Inventory Method (HMIM), a novel method to measure possession and use of OTC medications. METHODS: We benchmarked, adapted, and standardized prior approaches to medication inventory to develop a method capable of addressing the limitations of existing methods. We then conducted a pilot study of the HMIM among older adults. Eligible participants were aged ≥60 years, reported purchasing or considering purchasing OTC medication, and screened for normal cognition. Interviews were conducted both in person and remotely. When possible, photographs of all OTC medications were obtained with participant consent and completion times were recorded for both in-person and remote modalities. RESULTS: In total 51 participants completed the pilot study. Home medication inventories were conducted in-person (n = 15) and remotely (n = 36). Inventories were completed in a mean (SD) of 20.2 min (12.7), and 96 % of inventories completed within 45 min. A total of 390 OTC medications were possessed by participants, for a mean (SD) of 7.6 (6.3) per participant. No differences in duration of interviews or number of medications reported were identified between in-person and remote modalities. Anticholinergic medications, a class targeted in the pilot as potentially harmful to older adults, were possessed by 31 % of participants, and 14 % of all participants reported use of such a medication within the previous 2 weeks. CONCLUSIONS: Implementing the HMIM using in-person and remote modalities is a feasible and ostensibly reproducible method for collecting OTC medication possession and use information. Larger studies are necessary to further generalize HMIM feasibility and reliability in diverse populations.

Adapting a community pharmacy intervention to improve medication safety.

BACKGROUND: Community pharmacies are an ideal location to address challenges of over-the-counter medication safety, yet many successful interventions are only tested in a few pharmacies without expansion, creating unrealized opportunities to improve patient care on a larger scale. Scaling up to numerous pharmacies can be challenging because each community pharmacy has unique needs and layouts and requires individualized adaptation. OBJECTIVES: This paper reports techniques for (a) adapting a community pharmacy intervention to fit the unique physical layout and patient needs of health system pharmacy sites without increasing staff workload, (b) identifying strategies to gather feedback on adaptations from stakeholders, and (c) developing materials to share with pharmacy champions for them to independently implement and sustain the intervention in their organization. PRACTICE DESCRIPTION: The study team collaborated with Aurora Pharmacy, Inc to develop an intervention designed to increase awareness of safe over-the-counter medication use for older adults. PRACTICE INNOVATION: Senior Safe, a community pharmacy-based intervention, was designed, implemented, and tested using the Exploration, Preparation, Implementation, and Sustainment implementation framework. EVALUATION METHODS: Senior Safe was adapted through pilot testing and a randomized control trial. Feedback was collected from key stakeholders, including pharmacy staff, older adults, and a research advisory group. RESULTS: A finalized version of Senior Safe, as well as an implementation package, was provided to Aurora Pharmacy to integrate into all 63 sites. CONCLUSION: This multiphase study illustrated that refining an intervention is possible and welcomed by pharmacy staff, but it requires time, resources, and funds to create an impactful, sustainable community pharmacy intervention.

An mHealth Design to Promote Medication Safety in Children with Medical Complexity.

BACKGROUND: Children with medical complexity (CMC) are uniquely vulnerable to medication errors and preventable adverse drug events because of their extreme polypharmacy, medical fragility, and reliance on complicated medication schedules and routes managed by undersupported family caregivers. There is an opportunity to improve CMC outcomes by designing health information technologies that support medication administration accuracy, timeliness, and communication within CMC caregiving networks. OBJECTIVES: The present study engaged family caregivers, secondary caregivers, and clinicians who work with CMC in a codesign process to identify: (1) medication safety challenges experienced by CMC caregivers and (2) design requirements for a mobile health application to improve medication safety for CMC in the home. METHODS: Study staff recruited family caregivers, secondary caregivers, and clinicians from a children's hospital-based pediatric complex care program to participate in virtual codesign sessions. During sessions, the facilitator-guided codesigners in generating and converging upon medication safety challenges and design requirements. Between sessions, the research team reviewed notes from the session to identify design specifications and modify the prototype. After design sessions concluded, each session recording was reviewed to confirm that all designer comments had been captured. RESULTS: A total of N = 16 codesigners participated. Analyses yielded 11 challenges to medication safety and 11 corresponding design requirements that fit into three broader challenges: giving the right medication at the right time; communicating with others about medications; and accommodating complex medical routines. Supporting quotations from codesigners and prototype features associated with each design requirement are presented. CONCLUSION: This study generated design requirements for a tool that may improve medication safety by creating distributed situation awareness within the caregiving network. The next steps are to pilot test tools that integrate these design requirements for usability and feasibility, and to conduct a randomized control trial to determine if use of these tools reduces medication errors.

Using Protection Motivation Theory to develop a survey of over-the-counter decision-making by older adults.

BACKGROUND: Older adults (aged 65+) are responsible for 30% of the over-the-counter (OTC) medication use in the US. Each year, over 175,000 older adults are hospitalized due to OTC-related adverse drug events (ADEs). A major barrier to improving OTC use has been the dearth of actionable research on factors that affect older adult decision-making during OTC selection. Risk perception and health literacy are two such factors known to impact health behavior. However, to date no studies have characterized risk perceptions of OTCs nor how they relate to health literacy in the decision-making processes of older adults. OBJECTIVE: This paper presents the development and validation of a survey instrument to measure older adults' risk perception toward over-the-counter medications. The survey also explores the relation of risk perception to health literacy efficacy. METHODS: The Protection Motivation Theory (PMT) and the Tripartite Risk Perception Model (TRIRISK model) formed the basis for conceptualizing relationships between this study's constructs of interest. The utility of the PMT and the TRIRISK model in the context of OTC medication safety was tested in a survey of 103 older adults; exploratory factor analysis (EFA) and Spearman's correlation coefficients were used to test construct validity. RESULTS: The EFA yielded a 4-factor model of protection motivation, which included deliberative risk perception, emotional risk perception, perceived threat severity, and perceived coping efficacy. The EFA-based item reduction resulted in a final 14-item OTC Protection Motivation survey. CONCLUSION: The survey generated through this study is a tool for characterizing older adult risk perceptions of OTCs. The development of a measure of OTC risk perceptions is a promising step toward designing and evaluating patient-centered interventions to improve older adult medication safety.

CancelRx case study: implications for clinic and community pharmacy work systems.

BACKGROUND: Medication prescribing and discontinuation processes are complex and involve the patient, numerous health care professionals, organizations, health information technology (IT). CancelRx is a health IT that automatically communicates medication discontinuations from the clinic electronic health record to the community pharmacy dispensing platform, theoretically improving communication. CancelRx was implemented across a Midwest academic health system in October 2017. The health system also operates 15 outpatient community pharmacies. OBJECTIVE: The goal of this qualitative study was to describe how both the clinic and community pharmacy work systems change and interact over time regarding medication discontinuations, before and after CancelRx implantation. APPROACH: Medical Assistants (n = 9), Community Pharmacists (n = 12), and Pharmacy Administrators (n = 3), employed by the health system were interviewed across 3-time periods between 2017 and 2018- 3-months prior to CancelRx implementation, 3-months after CancelRx implementation, and 9-months after CancelRx implementation. Interviews were audio recorded, transcribed, and conducted a hybrid analysis with deductive content analysis following the Systems Engineering Initiative for Patient Safety (SEIPS) framework and inductive analysis to capture additional codes and themes. KEY RESULTS: CancelRx changed the medication discontinuation process at both clinics and community pharmacies. In the clinics, the workflows and medication discontinuation tasks changed over time while MA roles and clinic staff communication practices remained variable. In the pharmacy, CancelRx automated and streamlined how medication discontinuation messages were received and processed, but also increased workload for the pharmacists and introduced new errors. CONCLUSIONS: This study utilizes a systems approach to assess disparate systems within a patient network. Future studies may consider health IT implications for systems that are not in the same health system as well as assessing the role of implementation decisions on health IT use and dissemination.

Applying RE-AIM to examine the impact of an implementation facilitation package to scale up a program for Veterans with chronic obstructive pulmonary disease.

BACKGROUND: US Veterans are four times more likely to be diagnosed with chronic obstructive pulmonary disease (COPD) compared to the civilian population with no care model that consistently improves Veteran outcomes when scaled. COPD Coordinated Access to Reduce Exacerbations (CARE) is a care bundle intended to improve the delivery of evidence-based practices to Veterans. To address challenges to scaling this program in the Veterans' Health Administration (VA), the COPD CARE Academy (Academy), an implementation facilitation package comprised of five implementation strategies was designed and implemented. METHODS: This evaluation utilized a mixed-methods approach to assess the impact of the Academy's implementation strategies on the RE-AIM framework implementation outcomes and the extent to which they were effective at increasing clinicians' perceived capability to implement COPD CARE. A survey was administered one week after Academy participation and a semi-structured interview conducted 8 to 12 months later. Descriptive statistics were calculated for quantitative items and thematic analysis was used to analyze open-ended items. RESULTS: Thirty-six clinicians from 13 VA medical centers (VAMCs) participated in the Academy in 2020 and 2021 and 264 front-line clinicians completed COPD CARE training. Adoption of the Academy was indicated by high rates of Academy session attendance (90%) and high utilization of Academy resources. Clinicians reported the Academy to be acceptable and appropriate as an implementation package and clinicians from 92% of VAMCs reported long-term utilization of Academy resources. Effectiveness of the Academy was represented by clinicians' significant increases (p < 0.05) in their capability to complete ten implementation tasks after Academy participation. CONCLUSIONS: This evaluation found that the use of implementation facilitation paired with additional strategies enhanced the capacity of clinicians to implement COPD CARE. Future assessments are needed to explore post-academy resources that would help VAMCs to strategize localized approaches to overcome barriers.

Clinical decision support systems in community pharmacies: a scoping review.

OBJECTIVE: Clinical decision support systems (CDSS) were implemented in community pharmacies over 40 years ago. However, unlike CDSS studies in other health settings, few studies have been undertaken to evaluate and improve their use in community pharmacies, where billions of prescriptions are filled every year. The aim of this scoping review is to summarize what research has been done surrounding CDSS in community pharmacies and call for rigorous research in this area. MATERIALS AND METHODS: Six databases were searched using a combination of controlled vocabulary and keywords relating to community pharmacy and CDSS. After deduplicating the initial search results, 2 independent reviewers conducted title/abstract screening and full-text review. Then, the selected studies were synthesized in terms of investigational/clinical focuses. RESULTS: The selected 21 studies investigated the perception of and response to CDSS alerts (n = 7), the impact of CDSS alerts (n = 7), and drug-drug interaction (DDI) alerts (n = 8). Three causes of the failures to prevent DDIs of clinical importance have been noted: the perception of and response to a high volume of DDI alerts, a suboptimal performance of CDSS, and a dearth of sociotechnical considerations for managing workload and workflow. Additionally, 7 studies emphasized the importance of utilizing CDSS for a specific clinical focus, ie, antibiotics, diabetes, opioids, and vaccinations. CONCLUSION: Despite the range of topics dealt in the last 30 years, this scoping review confirms that research on CDSS in community pharmacies is limited and disjointed, lacking a comprehensive approach to highlight areas for improvement and ways to optimize CDSS utilization.

Sociotechnical Work System Approach to Occupational Fatigue.

INTRODUCTION TO THE PROBLEM: Occupational fatigue is a characteristic of excessive workload and depicts the limited capacity to complete demands. The impact of occupational fatigue has been studied outside of health care in fields such as transportation and heavy industry. Research in health care professionals such as physicians, medical residents, and nurses has demonstrated the potential for occupational fatigue to affect patient, employee, and organizational outcomes. A conceptual framework of occupational fatigue that is informed by a sociotechnical systems approach is needed to (1) describe the multidimensional facets of occupational fatigue, (2) explore individual and work system factors that may affect occupational fatigue, and (3) anticipate downstream implications of occupational fatigue on employee well-being, patient safety, and organizational outcomes. CONCEPTUAL FRAMEWORK OF OCCUPATIONAL FATIGUE: The health care professional occupational fatigue conceptual framework is outlined following the Systems Engineering Initiative for Patient Safety (SEIPS) model and adapted from the Conceptual Model of Occupational Fatigue in Nursing. Future research may apply this conceptual framework to health care professionals as a tool to describe occupational fatigue, identify the causes, and generate solutions. Interventions to mitigate and resolve occupational fatigue must address the entire sociotechnical system, not just individual or employee changes.

Applying RE-AIM to examine the impact of an implementation facilitation package to scale up a program for Veterans with Chronic Obstructive Pulmonary Disease.

Background: U.S. Veterans are four-times more likely to be diagnosed with Chronic Obstructive Pulmonary Disease (COPD) compared to the civilian population with no care model that consistently improves Veteran outcomes when scaled. COPD Coordinated Access to Reduce Exacerbations (CARE) is a care bundle intended to improve the delivery of evidence-based practices to Veterans. To address challenges to scaling this program in the Veterans' Health Administration (VA), the COPD CARE Academy (Academy), an implementation facilitation package comprised of four implementation strategies was designed and implemented. Methods: This evaluation utilized a mixed-methods approach to assess the impact of the Academy's implementation strategies on the RE-AIM framework implementation outcomes and the extent to which they were effective at increasing clinicians' perceived capability to implement COPD CARE. A survey was administered one week after Academy participation and a semi-structured interview conducted eight to 12 months later. Descriptive statistics were calculated for quantitative items and thematic analysis was used to analyze open-ended items. Results: Thirty-six clinicians from 13 VA medical centers (VAMCs) participated in the Academy in 2020 and 2021 and 264 front-line clinicians completed COPD CARE training. Adoption of the Academy was indicated by high rates of Academy completion (97%), session attendance (90%), and high utilization of Academy resources. Clinicians reported the Academy to be acceptable and appropriate as an implementation package and clinicians from 92% of VAMCs reported long-term utilization of Academy resources. Effectiveness of the Academy was represented by clinicians' significant increases (p < 0.05) in their capability to complete ten implementation tasks after Academy participation. Conclusions: This evaluation found that the use of implementation facilitation paired with additional strategies seemed to demonstrate positive implementation outcomes across all RE-AIM domains and identified areas for potential improvement. Future assessments are needed to explore post-academy resources that would help VAMCs to strategize localized approaches to overcome barriers.

Elevating Safe Use of Over-The-Counter Medications in Older Adults: A Narrative Review of Pharmacy Involved Interventions and Recommendations for Improvement.

Over-the-counter (OTC) medications are products that have been made easily accessible to allow patients to treat common ailments without a prescription and the cost of a doctor's visit. These medications are generally considered safe; however, there is still a potential for these medications to lead to adverse health outcomes. Older adults (ages 50+) are especially susceptible to these adverse health outcomes, due to age-related physiological changes, a higher prevalence of comorbidities, and prescription medication use. Many OTC medications are sold in pharmacies, which provides pharmacists and technicians with the opportunity to help guide safe selection and use for these medications. Therefore, community pharmacies are the ideal setting for OTC medication safety interventions. This narrative review summarizes the findings of pharmacy-involved interventions that promote safe OTC medication use for older adults.

CancelRx Case Study: Implications for Clinic and Community Pharmacy Work Systems.

Background: The medication prescribing, and de-prescribing process is complex with numerous actors, organizations, and health information technology (IT). CancelRx is a health IT that automatically communicates medication discontinuations from the clinic electronic health record to the community pharmacy's dispensing platform, theoretically improving communication. CancelRx was implemented across a Midwest academic health system in October 2017. Objective: The goal of this study was to describe how both the clinic and community pharmacy work systems change and interact over time regarding medication discontinuations. Approach: Medical Assistants (n = 9), Community Pharmacists (n = 12), and Pharmacy Administrators (n =3), employed by the health system were interviewed across 3-time periods- 3-months prior to CancelRx implementation, 3-months after CancelRx implementation, and 9-months after CancelRx implementation. Interviews were audio recorded, transcribed, and analyzed via deductive content analysis. Key Results: CancelRx changed the medication discontinuation process at both clinics and community pharmacies. In the clinics, the workflows and medication discontinuation tasks changed over time while MA roles and clinic staff communication practices remained variable. In the pharmacy, CancelRx automated and streamlined how medication discontinuation messages were received and processed, but also increased workload for the pharmacists and introduced new errors. Conclusions: This study utilizes a systems approach to assess disparate systems within a patient network. Future studies may consider health IT implications for systems that are not in the same health system as well as assessing the role of implementation decisions on health IT use and dissemination.

Subjective Perceptions of Occupational Fatigue in Community Pharmacists.

INTRODUCTION: Community retail pharmacists are experiencing unsafe levels of stress and excessive demands within the workplace. One aspect of workload stress that has been overlooked among pharmacists is occupational fatigue. Occupational fatigue is a characteristic of excessive workload including increased work demands and reduced capacity and resources to complete the work. The goal of this study is to describe the subjective perceptions of occupational fatigue in community pharmacists by using (Aim 1) a previously developed Pharmacist Fatigue Instrument and (Aim 2) semi-structured interviews. METHODS: Wisconsin community pharmacists were eligible to participate in the study and recruited via a practice-based research network. Participants were asked to complete a demographic questionnaire, a Pharmacist Fatigue Instrument, and semi-structured interview. Survey data were analyzed using descriptive statistics. Interview transcripts were analyzed using qualitative deductive content analysis. RESULTS: Totally, 39 pharmacists participated in the study. From the Pharmacist Fatigue Instrument, 50% of the participants stated they had times where they were not able to go above and beyond standard patient care on more than half of the days they worked. A total of 30% of the participants reported that they found it necessary to take short-cuts when providing patient care on more than half of the days they worked. Pharmacist interviews were separated into overarching themes including mental fatigue, physical fatigue, active fatigue, and passive fatigue. CONCLUSIONS: The findings highlighted the pharmacists' feelings of despair and mental fatigue, fatigue's connectedness to interpersonal relationships, and the complex nature of pharmacy work systems. Interventions aimed at improving occupational fatigue in community pharmacies should consider key themes of fatigue that pharmacists are experiencing.

"What brought you in today?": Modeling patient-provider clinic visits to characterize rural providers' antibiotic treatment decisions.

BACKGROUND: Designing clinical decision support (CDS) tools is challenging because clinical decision-making must account for an invisible task load: incorporating non-linear objective and subjective factors to make an assessment and treatment plan. This calls for a cognitive task analysis approach. OBJECTIVES: The objectives of this study were to 1.) understand healthcare providers' decision making during a typical clinic visit, and 2.) explore how antibiotic treatment decisions are made when they arise. METHODS: Two cognitive task analysis methods were applied - Hierarchical Task Analysis (HTA) and Operations Sequence Diagramming (OSD) - to 39 h of observational data collected at family medicine, urgent care, and emergency medicine clinical sites. RESULTS: The resulting HTA models included a coding taxonomy detailing ten cognitive goals and associated sub-goals and demonstrated how the goals occur as interactions between the provider and electronic health record, the patient, and the physical clinic environment. Although the HTA detailed resources for antibiotic treatment decisions, antibiotics were a minority of drug classes ordered. The OSD shows the sequence of events and when decisions are made solely at the provider level and when shared decision making occurs with the patient. Qualitative data from the observations informed a constructed vignette case example portraying select tasks from the HTA. CONCLUSIONS: These findings emphasize that the scope of disease states presenting to a generalist clinical setting is broad and could include acute exacerbations of rare diseases within a time-pressured environment. CDS must be accessible, time efficient, and fit within the resource gathering task before treatment decisions are made.

Evaluation of an implementation package to deliver the COPD CARE service.

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death worldwide and is estimated to be the leading cause of death in the next 15 years. Patients with COPD suffer from persistent chronic cough, sputum production and exacerbations leading to deteriorating lung function, worsening quality of life and loss of independence. While evidence-based interventions exist to improve the well-being of patients with COPD, incorporation of these interventions into routine clinical care is challenging. Chronic Obstructive Pulmonary Disease Coordinated Access to Reduce Exacerbations (COPD CARE) is a team-based, coordinated care transitions service integrating evidence-based interventions for COPD management within the patient care delivery model to reduce readmissions. This evaluation considers the process of scaling the COPD CARE service across medical facilities using an implementation package designed for service expansion. The implementation package was developed at the United States Veterans Health Administration and implemented at two medical centres. Core dissemination and implementation science methods were applied to guide design and delivery of the implementation package.The aims of this evaluation were to (1) evaluate the impact of the implementation package on use of evidence-based interventions for COPD management and (2) explore clinician perceptions of the implementation package. This prospective mixed-methods quality improvement project included two Plan Do Check Act (PDCA) cycles conducted over a 24-month period. Electronic health record data demonstrated significant improvements in the count of evidence-based interventions incorporated into routine clinical care after training completion (p<0.001), offering preliminary effectiveness of the package to improve uptake of best practices for COPD management. Clinician perceptions of the implementation package, measured by questionnaire at multiple time points, demonstrated significant improvements for all scales at the end of the final PDCA cycle. Clinicians described the implementation package as positively impacting clinician confidence, interprofessional collaboration and patient care delivery.

Defining and enhancing collaboration between community pharmacists and primary care providers to improve medication safety.

INTRODUCTION: Over 4 billion prescriptions are dispensed each year to patients in the United States, with the number of prescriptions continuing to increase. There is a growing recognition of pharmacists' potential in improving medication safety in community settings, in collaboration with primary care providers (PCPs). However, the nature of collaboration has not been well defined, and barriers and strategies are not articulated. AREA COVERED: For this narrative review, published studies were retrieved from PubMed between January 2000 and December 2020. Search terms included "patient safety," "medication safety," "collaboration," "primary care physician," and "community pharmacy." Resulting articles were categorized as follows: defining collaboration, types of collaboration, and barriers and solutions to collaboration. EXPERT OPINION: It is important to understand the factors within a community pharmacy setting that limit or facilitate community pharmacists' participation in medication safety activities. Strategies such as medication review are a common form of collaboration. Barriers to collaboration include misconceptions regarding roles and differences in access to clinical information and community pharmacy practice variability. Future recommendations include increasing training and utilization of pharmacists/PCP teams, increasing community pharmacists' practice in emerging roles, and expanding the community pharmacist role in transitions of care from the hospital to the community.

Discordance in Addressing Opioid Crisis in Rural Communities: Patient and Provider Perspectives.

Providing patient-centered care to manage chronic pain and opioid use disorder (OUD) is associated with improved health outcomes. However, adopting a holistic approach to providing care is often challenging in rural communities. This study aims to identify and contrast challenges to providing patient-centered care from the perspective of patients and providers. A participatory design approach was adopted to elicit the perceptions of providers and patients with lived experiences of chronic pain and/or OUD in Jefferson County, Wisconsin. Two focus groups were conducted with each stakeholder group to identify problems that participants face with respect to chronic pain management and OUD and possible solutions. Four interviews were conducted with providers experienced in chronic pain management. Analysis of focus group sessions and interviews show consensus among patients and providers that lack of behavioral health and recovery resources create barriers to effectively manage OUD and chronic pain. However, there was discordance among the two groups about other barriers such as patient and provider attitudes, tapering approach, and access to medications for OUD. This tension among patients and providers can influence patients' retention in therapy. More efforts are needed to mitigate stigma among providers in rural communities and support psychosocial needs of patients.

Effectiveness and sustainment of a tailored over-the-counter medication safety intervention in community pharmacies: A randomized controlled trial.

INTRODUCTION: The Senior Section is a continuation of a previous intervention that aims to address a gap in medication safety, specifically related to older adult selection and use of over-the-counter medications. The purpose of this paper is to describe the protocol of this study. METHODS: This study will occur in three phases: an adaptation phase, an effectiveness phase using a randomized controlled trial, and a sustainment phase. This study will take place in conjunction with administrative leadership and pharmacy sites of a regional Midwest integrated health system. Eye tracking technology will inform the adaptation of the intervention and demonstrate effectiveness in the randomized controlled trial. Following the randomized controlled trial, the health system will implement the intervention without research team support. Fidelity and long-term effectiveness outcomes will be collected to demonstrate sustainment. DISCUSSION: The potential implications of this study are a complete and sustained redesign of the pharmacy setting to include educational and directional materials on medication safety, leading to a decrease in over-the-counter medication misuse in older adults. This project could provide a road map for pharmacy organizations to tailor and adopt the Senior Section, to ultimately reduce inappropriate over-the-counter medication use in older adults.

CancelRx implementation: Observed changes to medication discontinuation workflows over time.

Introduction: When patients are seen in an ambulatory outpatient clinic, such as their primary care provider's office, the prescriber often stops or discontinues medications. Although medication discontinuations are documented in the clinic's health record, this information may not be communicated to the pharmacy. Within the last decade, CancelRx has attempted to address this issue by sending a message from the clinic to the pharmacy when a medication has been discontinued or changed. Objectives: This project studied pharmacy medication discontinuation workflows and pharmacists' perspectives at 3 UW Health outpatient pharmacies before and after implementation of CancelRx. Methods: CancelRx was implemented at UW Health in October 2017. Pharmacists from 3 outpatient pharmacies were observed at 3 distinct time points. The research team conducted 9 observations 3-months before CancelRx implementation (July 2017). Additionally, 9 observations were completed at 3-months after CancelRx implementation (January 2018) and at 9-months after CancelRx implementation (July 2018). Collective case study and comparative workflow modeling were used in this study. Observation field notes were deductively coded and aggregated to determine task frequency, occurrence, and patterns using an interpretivist theoretical approach. Results: During the study, 106 medication discontinuation instances (referred to as cases) were observed; 28 cases 3-months prior to CancelRx, 59 cases 3-months after CancelRx, and 16 cases 9-months after CancelRx. Medication discontinuation tasks aligned with the predetermined workflow: receiving and investigating the discontinuation messages, matching the message to the medication in the patient's profile and discontinuing it, documenting and communicating the message to others as necessary. After implementing CancelRx, the workflow changed as most pharmacists eliminated the investigating and documenting tasks. Conclusions: This study provided insight into the medication discontinuation workflow in community pharmacies, especially after implementing CancelRx. Organizations are recommended to proactively consider the implications for novel health information technology before implementation to anticipate workflow and pharmacy practice changes and improve acceptance and effectiveness.

Impact of CancelRx on discontinuation of controlled substance prescriptions: an interrupted time series analysis.

BACKGROUND: Prescription opioid misuse is a serious national crisis; in 2018 the top drugs involved in prescription overdose deaths included pain medications (opioids), benzodiazepines, and stimulants. Health information technology (health IT) provides a means to address this crisis through technologies that streamline the prescribing and discontinuation process. CancelRx is a health IT function that communicates when medications, such as controlled substances, are discontinued at the clinic and therefore should not be filled at the pharmacy. Prior to CancelRx, the communication of discontinued medications was a manual process, requiring the patient or a clinic staff member to personally contact the pharmacy to inform them of the change. The objective of this study was to assess how controlled substance medication discontinuations were communicated over time, before and after the implementation of CancelRx. METHODS: Secondary data from a midwestern academic health system electronic health record and pharmacy platform were collected 12-months prior to CancelRx implementation and for 12-months post implementation. The study utilized an interrupted time series analysis (ITSA) to capture the percentage of controlled substance medications that were discontinued in the clinic's electronic health record and discontinued in the pharmacy's dispensing software. The ITSA plotted the percentage of successful discontinuation messages over time, particularly after the health system's implementation of CancelRx, a novel technology. RESULTS: After CancelRx implementation there was an immediate (change = 77.7 percentage point) and significant (p < 0.001) increase in the number of controlled substance medications that were successfully discontinued at the pharmacy after being discontinued in the clinic. This change was sustained in the year following CancelRx (slope = 0.03 pp, 95% CI - 0.050 to 0.110) and did not revert to pre-CancelRx levels. The health IT functionality was able to effectively complete discontinuation tasks and potentially reduce workload for clinic staff. CONCLUSIONS: Overall, this study demonstrates the role that technology can play in promoting communication between clinics and pharmacies, especially when medications such as controlled substances are discontinued.