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eMedication – improving medication management using information technology
Linnaeus University, Faculty of Health and Life Sciences, Department of Medicine and Optometry. (eHälsoinstitutet ; eHealth Institute)ORCID iD: 0000-0003-1549-2469
2014 (English)Doctoral thesis, comprehensive summary (Other academic)Alternative title
eMedicinering – IT-stöd i läkemedelsprocessen (Swedish)
Abstract [en]

Medication is an essential part of health care and enables the prevention andtreatment of many conditions. However, medication errors and drug-relatedproblems (DRP) are frequent and cause suffering for patients and substantial costsfor society. eMedication, defined as information technology (IT) in themedication management process, has the potential to increase quality, efficiencyand safety but can also cause new problems and risks.In this thesis, we have studied the employment of IT in different steps of themedication management process with a focus on the user's perspective. Sweden isone of the leading countries when it comes to ePrescribing, i.e. prescriptionstransferred and stored electronically. We found that ePrescribing is well acceptedand appreciated by pharmacists (Study I) and patients (Study II), but that therewas a need for improvement in several aspects. When the pharmacy market inSweden was re-regulated, four new dispensing systems were developed andimplemented. Soon after the implementation, we found weaknesses related toreliability, functionality, and usability, which could affect patient safety (StudyIII). In the last decade, several county councils in Sweden have implementedshared medication lists within the respective region. We found that physiciansperceived that a regionally shared medication list generally was more complete butoften not accurate (Study IV). Electronic expert support (EES) is a decisionsupport system which analyses patients´ electronically-stored prescriptions in orderto detect potential DRP, i.e. drug-drug interactions, therapy duplication, highdose, and inappropriate drugs for geriatric or pediatric patients. We found thatEES detected potential DRP in most patients with multi-dose drug dispensing inSweden (Study V), and that the majority of alerts were regarded as clinicallyrelevant (Study VI).For an improved eMedication, we need a holistic approach that combinestechnology, users, and organization in implementation and evaluation. The thesissuggests a need for improved sharing of information and support for decisionmaking, coordination, and education, as well as clarification of responsibilitiesamong involved actors in order to employ appropriate IT. We suggestcollaborative strategic work and that the relevant authorities establish guidelinesand requirements for IT in the medication management process.

Abstract [sv]

Läkemedel förbättrar och förlänger livet för många och utgör en väsentlig del av dagens hälso- och sjukvård men om läkemedel tas i fel dos eller kombineras felaktigt med varandra kan behandlingen leda till en försämrad livskvalitet, sjukhusinläggningar och dödsfall. En del av dessa problem skulle kunna förebyggas med rätt information till rätt person vid rätt tidpunkt och i rätt form. Informationsteknik i läkemedelsprocessen har potentialen att öka kvalitet, effektivitet och säkerhet genom att göra information tillgänglig och användbar men kan också innebära problem och risker. Det är dock en stor utmaning att i läkemedelsprocessen föra in effektiva och användbara IT-system som stödjer och inte stör personalen inom sjukvård och på apotek, skyddar den känsliga informationen för obehöriga och dessutom fungerar tillsammans med andra system. Dagens IT-stöd i läkemedelsprocessen är otillräckliga. Till exempel saknar läkare, farmaceuter och patienter ofta tillgång på fullständig och korrekt information om en patients aktuella läkemedel; det händer att fel läkemedel blir utskrivet eller expedierat på apotek; och bristande eller långsamma system skapar frustration hos användarna. Dessutom är det flera delar av läkemedelsprocessen som fortfarande är pappersbaserade. Därför är det viktigt att utvärdera IT-system i läkemedelsprocessen.

Vi har studerat IT i olika delar av läkemedelsprocessen, före eller efter införandet, framför allt utifrån användarnas perspektiv. Sverige har lång erfarenhet och tillhör de ledande länderna i världen när det gäller eRecept, det vill säga recept som skickas och lagras elektroniskt. I två studier fann vi att eRecept är väl accepterat och uppskattat av farmaceuter (Studie I) och patienter (Studie II), men att det finns behov av förbättringar. När apoteksmarknaden omreglerades 2009 infördes fyra nya receptexpeditionssystem på apoteken. Vi fann att det efter införandet uppstod problem med användbarhet, tillförlitlighet och funktionalitet som kan ha inneburit en risk för patientsäkerheten (Studie III). I Sverige har man inom flera sjukvårdsregioner infört gemensamma elektroniska läkemedelslistor. I en av studierna kunde vi visa att detta har inneburit en ökad tillgänglighet av information, men att en gemensam lista inte alltid blir mer korrekt och kan innebära en ökad risk att känslig information nås av obehöriga (Studie IV).

I två av studierna undersöktes beslutsstödssystemet elektroniskt expertstöd (EES):s potential som stöd för läkare att upptäcka läkemedelsrelaterade problem till exempel om en patient har två olika läkemedel som inte passar ihop, eller ett läkemedel som kanske är olämpligt för en äldre person. Studierna visade att EES gav signaler för potentiella problem hos de flesta patienter med dosdispenserade läkemedel i Sverige (Studie V), och läkarna ansåg att majoriteten av signalerna är kliniskt relevanta och att några av signalerna kan leda till förändringar i läkemedelsbehandlingen (Studie VI).

Sammantaget visar avhandlingen att IT-stöd har blivit en naturlig och nödvändig del i läkemedelsprocessen i Sverige men att flera problem är olösta. Vi fann svagheter med användbarhet, tillförlitlighet och funktionalitet i de använda IT-systemen. Patienterna är inte tillräckligt informerade och delaktiga i sin läkemedelsbehandling. Läkare och farmaceuter saknar fullständig och korrekt information om patienters läkemedel, och de har i dagsläget inte tillräckliga beslutsstöd för att förebygga läkemedelsrelaterade problem. Eftersom läkemedelsprocessen är komplex med många aspekter som påverkar utfall behöver vi ett helhetstänkande när vi planerar, utvecklar, implementerar och utvärderar IT-lösningar där vi väger in både tekniska, sociala och organisatoriska aspekter. Avhandlingens resultat visar på ett behov av ökad koordination och utbildning samt förtydligande av ansvaret för inblandade aktörer. Vi föreslår gemensamt strategiskt arbete och att inblandade myndigheter tar fram vägledning och krav för IT i läkemedelsprocessen.

Place, publisher, year, edition, pages
Kalmar: Linnaeus University Press , 2014. , 76 p.
Series
Linnaeus University Dissertations, 188/2014
Keyword [en]
eMedication, eHealth, medication, ePrescribing, electronic prescribing, information technology, drug-related problems, clinical decision support system, health care, pharmacy, patient
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:lnu:diva-37167ISBN: 978-91-87925-15-3 (print)OAI: oai:DiVA.org:lnu-37167DiVA: diva2:748930
Public defence
2014-10-10, Nisbethska E312K, Kalmar, 10:00 (Swedish)
Opponent
Supervisors
Available from: 2014-09-24 Created: 2014-09-22 Last updated: 2017-01-19Bibliographically approved
List of papers
1. Swedish pharmacists value ePrescribing: a survey of a nation-wide implementation
Open this publication in new window or tab >>Swedish pharmacists value ePrescribing: a survey of a nation-wide implementation
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2010 (English)In: Journal of Pharmaceutical Health Services Research, ISSN 1759-8885, Vol. 1, no 1, 23-32 p.Article in journal (Refereed) Published
Abstract [en]

Objective

To evaluate Swedish pharmacists’ attitudes towards ePrescribing, including thetransfer of ePrescriptions, electronic storing of prescriptions and mail-order prescriptions.

Method

This study was conducted as a web-based survey among 500 randomly selectedSwedish community pharmacists. The questionnaire included open-ended questions,multiple-choice questions and statements to which respondents gave their degree ofagreement on a six-point Likert-type rating scale. Free-text answers were categorized intothe most commonly mentioned opinions. Differences in respondents’ general characteristicsand their level of satisfaction with ePrescribing were tested for significance using χ2test. The survey had a response rate of 52% (259/500). 96% (248/259) of the respondentswere female, and 76% (196/259) were aged 40–64 years.

Key findings

Swedish community pharmacists were generally satisfied with ePrescribing(98%, 253/259). No significant (P > 0.05) difference in the general satisfaction could beexplained by the respondents’ age, gender or years in practice. A majority of the respondentsregarded ePrescriptions and electronic storing of prescriptions as being safe for patients (95 and93% respectively), providing patient benefits (96 and 95% respectively), being cost-effectivefor the pharmacy (92 and 91% respectively) and contributing to better communication andrelationships with both patients and prescribers (62–88%). The positive aspects of ePrescribingmost frequently mentioned in free-text answers were being safe (72%, 187/259) and timesaving(55%, 143/259). However, several weaknesses with ePrescribing were also describedby the respondents, as well as suggestions for improvement.

Conclusion

Our nationwide survey of Swedish community pharmacists’ attitudestowards ePrescribing shows that pharmacists are generally satisfied with it, including thetransfer of ePrescriptions, electronic storing of prescriptions and to a lower degree mailorderprescriptions.

Place, publisher, year, edition, pages
Wiley-Blackwell, 2010
Keyword
community pharmacies, electronic prescribing, health informatics, information technology, pharmacists, prescriptions
National Category
Biomedical Laboratory Science/Technology
Research subject
Health and Caring Sciences, Health Informatics
Identifiers
urn:nbn:se:lnu:diva-2178 (URN)10.1211/jphsr/01.01.0012 (DOI)
Available from: 2010-04-06 Created: 2010-04-06 Last updated: 2017-01-19Bibliographically approved
2. Patients satisfied with e-prescribing in Sweden: a survey of a nationwide implementation
Open this publication in new window or tab >>Patients satisfied with e-prescribing in Sweden: a survey of a nationwide implementation
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2011 (English)In: Journal of pharmaceutical health services research, ISSN 1759-8885, Vol. 2, no 2, 97-105 p.Article in journal (Refereed) Published
Abstract [en]

Objective

To evaluate Swedish patients’ attitudes towards e-prescribing, including the transfer of e-prescriptions, electronic storing of prescriptions and mail-order prescriptions.

Methods

This study was a nationwide survey of attitudes among Swedish patients and was conducted as a postal questionnaire. The questionnaire was developed for the purpose of thisstudy and aimed to evaluate respondents’ views concerning e-prescribing, electronic storingof e-prescriptions and mail-order prescriptions from aspects including safety, personal benefits and effectiveness. A study population of 1500 individuals meeting the inclusioncriteria was randomly selected from a database of individuals in Sweden storing prescriptions electronically (n = 5 840 599).The response rate was 52% (739/1429).

Key findings

The vast majority of the respondents had a positive attitude towards e-prescriptions (85%, 628/739) and electronic storing of prescriptions (86%, 633/739), andregarded e-prescriptions to be safe (79%, 584/739), creating benefits for them (78%, 576/739) and promoting faster dispensing (69%, 512/739). Significant differences in attitudes towards e-prescriptions and electronic storing of prescriptions were detected between age groups. Patients storing all their prescriptions electronically had a more positive attitudetowards both e-prescriptions and electronic storing of prescriptions compared to patientswho stated they had paper prescriptions. The most common suggestion (n = 27) for improvement was to extend the information given about the services.

Conclusion

Our nationwide survey showed that a vast majority of Swedish patients had positive attitudes towards e-prescriptions and electronic storing of prescriptions. However, a need for extended information regarding e-prescribing was identified.

Keyword
community pharmacy, electronic prescribing, health informatics, information technology, patient satisfaction, prescriptions
National Category
Health Sciences
Research subject
Natural Science, Biomedical Sciences
Identifiers
urn:nbn:se:lnu:diva-13961 (URN)10.1111/j.1759-8893.2011.00040.x (DOI)2-s2.0-84860390021 (Scopus ID)
Available from: 2011-08-30 Created: 2011-08-30 Last updated: 2017-01-19Bibliographically approved
3. Implementation of information systems at pharmacies – a case study from the re-regulated pharmacy market in Sweden
Open this publication in new window or tab >>Implementation of information systems at pharmacies – a case study from the re-regulated pharmacy market in Sweden
2015 (English)In: Research in Social and Administrative Pharmacy, ISSN 1551-7411, E-ISSN 1934-8150, Vol. 11, no 2, E85-E99 p.Article in journal (Refereed) Published
Abstract [en]

Background

When the Swedish pharmacy market was re-regulated in 2009, Sweden moved from one state-owned pharmacy chain to several private pharmacy companies, and four new dispensing systems emerged to replace the one system that had previously been used at all Swedish pharmacies for more than 20 years.

Objectives

The aim of this case study was to explore the implementation of the new information systems for dispensing at pharmacies.

Methods

The vendors of the four dispensing systems in Sweden were interviewed, and a questionnaire was sent to the managers of the pharmacy companies. In addition, a questionnaire was sent to 350 pharmacists who used the systems for dispensing prescriptions.

Results

The implementation of four new dispensing systems followed a strict time frame set by political decisions, involved actors completely new to the market, lacked clear regulation and standards for functionality and quality assurance, was complex and resulted in variations in quality. More than half of the pharmacists (58%) perceived their current dispensing system as supporting safe dispensing of medications, 26% were neutral and 15% did not perceive it to support a safe dispensing. Most pharmacists (80%) had experienced problems with their dispensing system during the previous month. The pharmacists experienced problems included reliability issues, usability issues, and missing functionality.

Conclusion

In this case study exploring the implementation of new information systems for dispensing prescriptions at pharmacies in Sweden, weaknesses related to reliability, functionality and usability were identified and could affect patient safety. The weaknesses of the systems seem to result from the limited time for the development and implementation, the lack of comprehensive and evidence-based requirements for dispensing systems, and the unclear distribution of quality assurance responsibilities among involved stakeholders.

Place, publisher, year, edition, pages
Elsevier, 2015
Keyword
Electronic prescribing; E-health; Dispensing; Community pharmacy; Patient safety
National Category
Health Sciences Pharmaceutical Sciences
Research subject
Health and Caring Sciences; Natural Science, Biomedical Sciences
Identifiers
urn:nbn:se:lnu:diva-37161 (URN)10.1016/j.sapharm.2014.08.002 (DOI)000349671800004 ()25205612 (PubMedID)2-s2.0-84922354020 (Scopus ID)
Available from: 2014-09-22 Created: 2014-09-22 Last updated: 2018-01-11Bibliographically approved
4. Implementation of a shared medication list: physicians’ views on availability, accuracy and confidentiality
Open this publication in new window or tab >>Implementation of a shared medication list: physicians’ views on availability, accuracy and confidentiality
2014 (English)In: International Journal of Clinical Pharmacy, ISSN 2210-7703, E-ISSN 2210-7711, Vol. 36, no 5, 933-942 p.Article in journal (Refereed) Published
Abstract [en]

Background Physicians, patients and others involved need to have accurate information on patients’ current drug prescriptions available, and have that information protected from unauthorized access. During the past decade, many counties in Sweden have implemented regionally shared medication lists within health care. Objective The aim of this study was to describe physicians’ views on changes in accuracy, availability and confidentiality in the transition from local medication lists to a regionally shared medication list. Setting Health care units in four different counties of Sweden after the transition from local medication lists to a regionally shared medication list. The shared medication list was an integrated part of the electronic health record system in the respective counties, but the system and implementation process varied. Methods Physicians (n = 7) with experience of transition from local medication lists to a regionally shared medication list were interviewed in a semi-structured manner. Main outcome measure: Physicians’ views on changes in information risks, focusing on accuracy, availability and confidentiality. Results The transition from local medication lists to a shared medication list increased the availability of information: from being time consuming or not possible to access from other care givers to most information being available in one place. A regionally shared medication list was perceived as having the potential to provide a greater accuracy of information, but not always: the shared medication list was perceived as more complete but with more non-current drugs. On the other hand, a shared medication list implied an increased risk of violating patient privacy, placing greater demands on IT security in order to protect the confidentiality of information. Conclusion Physicians perceived a regionally shared medication list to increase the availability of information about current prescriptions and potentially the accuracy but may decrease the confidentiality of information. To implement a shared medication list, we recommend providing clear description of responsibilities and routines for normal activities as well as back-up routines, consider IT-security and data protection early, involve patients to improve the accuracy of the list as well as to monitor and evaluate the implementation.

Place, publisher, year, edition, pages
Springer, 2014
Keyword
Accuracy, Availability, Confidentiality, Information safety, Medication list, Medication reconciliation, Sweden
National Category
Social and Clinical Pharmacy
Research subject
Health and Caring Sciences
Identifiers
urn:nbn:se:lnu:diva-37162 (URN)10.1007/s11096-014-0012-0 (DOI)000343647000011 ()2-s2.0-84910608381 (Scopus ID)
Available from: 2014-09-22 Created: 2014-09-22 Last updated: 2018-01-11Bibliographically approved
5. Potential drug related problems detected by electronic expert support system in patients with multi-dose drug dispensing.
Open this publication in new window or tab >>Potential drug related problems detected by electronic expert support system in patients with multi-dose drug dispensing.
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2014 (English)In: International Journal of Clinical Pharmacy, ISSN 2210-7703, E-ISSN 2210-7711, Vol. 36, no 5, 943-952 p.Article in journal (Refereed) Published
Abstract [en]

Background Drug related problems (DRPs) are frequent and cause suffering for patients and substantial costs for society. Multi-dose drug dispensing (MDDD) is a service by which patients receive their medication packed in bags with one unit for each dose occasion. The clinical decision support system (CDSS) electronic expert support (EES) analyses patients’ prescriptions in the Swedish national e-prescription repository and provides alerts if potential DRPs are detected, i.e. drug–drug interactions, duplicate therapy, drug-disease contraindications, high dose, gender warnings, geriatric, and paediatric alerts. Objective To analyse potential DRPs in patients with MDDD, detected by means of EES. Setting A register study of all electronically stored prescriptions for patients with MDDD in Sweden (n = 180,059) March 5–June 5, 2013. Method Drug use and potential DRPs detected in the study population during the 3 month study period by EES were analysed. The potential DRPs were analysed in relation to patients’ age, gender, number of drugs, and type of medication. Main outcome measure Prevalence of potential DRPs measured as EES alerts. Results The study population was on average 75.8 years of age (±17.5, range 1–110) and had 10.0 different medications (±4.7, range 1–53). EES alerted for potential DRPs in 76 % of the population with a mean of 2.2 alerts per patient (±2.4, range 0–27). The older patients received a lower number of alerts compared to younger patients despite having a higher number of drugs. The most frequent alert categories were drug–drug interactions (37 % of all alerts), duplicate therapy (30 %), and geriatric warnings for high dose or inappropriate drugs (23 %). Psycholeptics, psychoanaleptics, antithrombotic agents, anti-epileptics, renin-angiotensin system agents, and analgesics represented 71 % of all drugs involved in alerts. Conclusions EES detected potential DRPs in the majority of patients with MDDD. The number of potential DRPs was associated with the number of drugs, age, gender, and type of medication. A CDSS such as EES might be a useful tool for physicians and pharmacists to assist in the important task of monitoring patients with MDDD for potential DRPs.

Place, publisher, year, edition, pages
Springer, 2014
Keyword
Clinical decision support system, Drug–drug interactions, Drug related problems, Multi-dose drug dispensing, Pharmacoepidemiology, Sweden
National Category
Social and Clinical Pharmacy
Research subject
Health and Caring Sciences
Identifiers
urn:nbn:se:lnu:diva-37165 (URN)10.1007/s11096-014-9976-z (DOI)000343647000012 ()24974220 (PubMedID)2-s2.0-84911383016 (Scopus ID)
Available from: 2014-09-22 Created: 2014-09-22 Last updated: 2018-01-11Bibliographically approved
6. Potential drug-related problems detected by electronic expert support system: physicians’ views on clinical relevance
Open this publication in new window or tab >>Potential drug-related problems detected by electronic expert support system: physicians’ views on clinical relevance
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2015 (English)In: International Journal of Clinical Pharmacy, ISSN 2210-7703, E-ISSN 2210-7711, Vol. 37, no 5, 941-948 p.Article in journal (Refereed) Published
Abstract [en]

Background Drug-related problems cause suffering for patients and substantial costs. Multi-dose drug dispensing is a service in which patients receive their medication packed in bags with one unit for each dose occasion. The electronic expert support system (EES) is a clinical decision support system that provides alerts if potential drug-related problems are detected among a patients’ current prescriptions, including drug–drug interactions, therapy duplications, high doses, drug-disease interactions, drug gender warnings, and inappropriate drugs and doses for geriatric or pediatric patients. Objective The aim of the study was to explore physicians’ views on the clinical relevance of alerts provided by EES. Furthermore we investigated if physicians performed any changes in drug treatment following the alerts and if there were any differences in perceived relevance and performed changes between different types of alerts and drugs. Setting Two geriatric clinics and three primary care units in Sweden. Method Prescribed medications for patients (n = 254) with multi-dose drug dispensing were analyzed for potential drug-related problems using EES. For each alert, a physician assessed clinical relevance and indicated any intended action. A total of 15 physicians took part in the study. Changes in drug treatment following the alerts were later measured. The relationship between variables was analyzed using Chi square test. Main outcome measure Physicians’ perceived clinical relevance of each alert, and changes in drug treatment following the alerts. ResultsPhysicians perceived 68 % (502/740) of EES alerts as clinically relevant and 11 % of all alerts were followed by a change in drug treatment. Clinical relevance and likelihood to make changes in drug treatment was related to the alert category and substances involved in the alert. Conclusion In most patients with multi-dose drug dispensing, EES detected potential drug-related problems, with the majority of the alerts regarded as clinically relevant and some followed by measurable changes in drug treatment.

Keyword
Alerts, Clinical decision support systems, Drug-related problems, Geriatric patients, Multi-dose drug dispensing, Relevance, Sweden
National Category
Other Health Sciences Health Care Service and Management, Health Policy and Services and Health Economy Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Health and Caring Sciences; Natural Science, Biomedical Sciences
Identifiers
urn:nbn:se:lnu:diva-37166 (URN)10.1007/s11096-015-0146-8 (DOI)000362415800040 ()26047943 (PubMedID)2-s2.0-84943200384 (Scopus ID)
Available from: 2014-09-22 Created: 2014-09-22 Last updated: 2017-12-05Bibliographically approved

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