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Author List:
Arar NH (VA/UTHSCSA)
Wen L (VA)
McGrath J (Trinity)
Steinbach R (UTHSCSA)
Pugh J (VA/UTHSCSA)
Objectives:
The use of electronic medical record (EMR) as part of the clinical information system holds enormous promise for improving the quality of care for chronically ill patients. The objective of this study is to assess the role of EMR in facilitating the content and process of patient-provider exchanges about medications during outpatient primary care visits.
Methods:
Fifty video-taped encounters for 6 staff physicians who had been using the EMR system were recorded at a VA primary care outpatient clinic. Patients were recruited as part of a convenience sample of patients attending the clinic on days the physicians were videotaping encounters. All videotaped encounters were transcribed and content analyzed applying conversation analysis and ethnomethodology techniques using Atlas.ti. software. A distinct exchange that conveyed one main idea related to medications was identified as the basic unit of analysis in this study. The analysis focused on patient-physician communications regarding medication: (1) process of care; practices that patients and physicians carry out to implement decisions concerning medication use, (2) themes; topics consistently emerge during the encounter regarding medications and (3) names; ways in which patients and physicians refer to medications during encounters. In-depth analysis of a subset of 20 encounters featuring patients with diabetes examined the extent to which initiation, expansion and conclusion regarding medications themes occurred by both parties during encounters.
Results:
On average 21.2 (range: 8-35; SD = 7.4) distinct exchanges per encounter were observed. Of those, 7(range: 1-15; SD = 3.6) exchanges, or 33% of the encounter time, were related to medications. Content analysis showed that of the 350 medication-related exchanges presented throughout the encounters, 196 (56%) were categorized as routine medication discussion such as ordering and/or refilling medications. Mail order issues, such receiving medication through mail, were the next most common medication-related exchanges (37; 10.6%) followed by partial adherence (31; 8.9%), self-regulation (26; 7.4%), alternative therapy/over the counter medication (23; 6.6%), side effects (21; 6%), and formulary issues (16; 4.6%). Patients and providers used three ways to name medications: generic/scientific name (147, 42%); general description such as color, size and/or shape of the medication (139, 39.7%); and brand name (64, 18.3%).
Direct observation and content analysis showed that the use of EMR facilitated the content and process of patient-physician communication regarding medications when patients: (1) were on multiple medications; (2) did not bring their medication to the encounter and were unsure of the medications they were taking; and (3) used general descriptions of the medication. In these cases, the EMR provided the physician with information on patient’s prescribed medication within the VA system. In addition, the EMR was utilized to enter patients’ new prescriptions, follow up on patients’ refills, and obtain information on the types and number of medications used by the patients and thus facilitated communication about medication processes of care.
In-depth analysis showed that 41% of exchanges included initiation by one party or initiation by two parties but no further discussion of the issue. 42% included initiation and expansion by both parties but not conclusion. Only 17% of exchanges contained complete medication exchanges (initiation, expansion and conclusion) by both parties.
Implications:
EMR facilitated content and process of patient-provider communications regarding medications during outpatient encounters, especially among patients who were on multiple medications and patients who used general descriptions to refer to their medications. The use of EMR stimulated exchanges about medication leading to further expansion about the topic. However, less than one fifth of the exchanges ended with clear conclusions by both parties regarding prescribed medication regimens.
Impacts:
The VA is a leader in utilizing clinical information system to improve patients care. Improvement in quality of outpatient care may be achievable by optimizing the use of EMR to enhance patient-provider communications.
