this is a well written literature review.
A key question across domains is, “how are patients/health agents/consumers persuaded to acquire certain drugs and take them as directed?”
The introduction of “concordance” to the literature on medication compliance and adherence—“adherence” is the most neutral, non-ideological, term for patient behavior, in use at least since the mid 1990s.
The question that concordance theorists have really asked is not, “how do we treat patients’ health beliefs more respectfully?” but rather, “how do we persuade patients to follow the advice of their doctors?”
We can frame a rhetorical question across domains: how are people persuaded to take drugs?
Several authors have written even-handedly about concordance and make clear that cooperation between physicians and patients is likely to lead to better, and more appropriate, use of medications. Elwyn, Edwards, and Britten write, “Concordance describes the process whereby the patient and doctor reach an agreement on how a drug will be used, if at all. In this process doctors identify and understand patients’ views and explain the importance of treatment, while patients gain an understanding of the consequences of keeping (or not keeping) to treatment.” Ferner writes, “Usually…the patient, who has most to gain by success and the most to lose from harm, should decide whether to have treatment, and the prescriber should provide information on the risks and benefits to help make the decision.”
It is easy to agree that cooperative, better-informed, and realistically-prepared patients are more likely to adhere to recommended treatments than those who are resistant, ill- informed, and unprepared.
So, “concordance,” with its egalitarian rhetoric, not only portrays physicians and patients as equals but also portrays all patients as equals—while, in truth and in practice, patients are not all equally well-equipped for consensual decision-making, and, certainly, not all physicians believe that they are. When one exits the concordance literature to enter other literature about patients, what becomes clear is that the respect for patients that is invoked as the key resource of concordance is not always available to be tapped.
The more consumers are aware of a drug, the more they will request it; arguably, if they request it, then, being in agreement with their physician on its prescription, they are more likely to adhere to treatment.
After the first audit we recommended that prescription scripts should be checked by the prescribing physician and re-checked by the nurse assistant in the clinic. Can be connected with this paper.
we strongly advocate more training of junior physicians to avoid these errors and to understand the potential hazards due to prescription errors. Same advice as this paper.
Computer-based prescribing systems may minimize the risk of errors due to illegible prescriptions. However there is a considerable financial investment and training involved which may be prohibitive for some institutions. From this external paper.
Knowledge of where and when errors are most likely to occur is generally the first step in prevention of prescription errors.[Top]
Reasons for interventions were grouped into 21 different categories. In some cases pharmacists cited multiple reasons (i.e., problems) for their intervention. Overall, 102 problematic e-prescription orders required intervention. Participating pharmacists documented a total of 113 reasons for intervention. The most common reason for pharmacists’ interventions on e-prescriptions was to supplement omit- ted information (32.7%), especially missing directions. Other common problems included insufficient (9.7%) or excessive (8.0%) dose.
They identify problems with overdose or wrong directions on how to take the medicine, drug-drug interaction etc. I suppose that these problems would interfere with patient compliance and adherence towards the medicine.
Prescribers may be more likely to make prescribing errors when using software or software options with which they are unfamiliar.
Pharmacists in this study recognized most problems independently of computer-assisted expert systems. However, pharmacists reported that computer systems were useful in identifying non-formulary medications, drug–drug interactions, and drug–allergy conflicts. These data once again emphasize that the currently available computer-assisted drug-use review decision support systems can be helpful but are not capable of supplanting the clinical judgment of the pharmacist. Can be connected with this paper.
Several recommendations can be made to improve the safety of e-prescribing in the community practice setting. First, physicians should perform their own e-prescription data entry or at least carefully review e-prescriptions that are entered by support staff before transmission to the pharmacy. Second, prescriber- side decision support software should be enabled and routinely used. Third, e-prescribing system safeguards and decision sup- port should be improved to more closely scrutinize new prescriptions to prevent commonly occurring errors. Fourth, when developing decision support systems for e-prescribing, special emphasis should be given to dosing error prevention.[Top]
Very important as to why we choose only literature based on the UK instead of globaly:
E-prescribing in the United States is defined as “the transmission, using electronic media, of prescription or prescription-related information, be- tween a prescriber, dispenser, pharmacy benefit manager (PBM), or health plan in either direction or through an intermediary, including an e-prescribing network. It includes, but is not limited to, two-way transmission between the point of care and the dispenser.” In other countries, such as the United Kingdom, electronic prescriptions can occur in 2 methods:
- a mechanism whereby prescribers can download medication data or generate an electronic prescription automatically from the core network, but the system still uses a paper prescription infrastructure
- generate an electronic encrypted signature and be allowed to transfer the prescription electronically as opposed to having the patient take the prescription to the pharmacy.
They use the same definition as : this paper
These results are in line with other evaluations of e-prescribing interventions. In their study of self-reported community pharmacists’ interventions on e-prescribing, Warholak and Rupp concluded that although e-prescribing can improve safety and effectiveness in patient care, still emerging technology can pose threats to medication safety and improvements need to be made to systems to improve the safety, effectiveness, and efficiency of e-prescribing.
When comparing e-prescribing with handwritten interventions, no significant differ- ences existed among intervention rates in this study (P¼.21). This indicates that despite the fact that e-prescribing is purported to be a safer mechanism (ie, reducing the amount of medication errors) for prescription transmission, no decrease in pharmacist intervention rate was seen. This may have been because of the fact that e-prescribing is relatively new in community pharmacy practice, and prescriber inexperience with the system may cause an initial increase in the number of prescribing is- sues that need intervention by the pharmacist.
Outpatient care, sometimes called “ambulatory care,” takes place at a doctor’s office or at a day health care clinic.
Improved patient safety. With basic e-prescribing, medication errors can be prevented, through the elimination of illegible handwriting, better dosage advice, and alerts for adverse drug-drug or drug-allergy interaction.
a PHR was defined in the project specification as:
… a digital tool that helps people to maintain their health and manage their care. It may do this by enabling them to capture their own health and care data, to communicate with health and care services, and/or to have access to their care record.
The literature review found evidence of unmet needs. Patient expectations were not being met by PHRs; in particular limited content of the record was being made available to patients and there was an inability to bring together records from different care settings into one place.
Recommendations for further research:
Understand what patients require from PHRs – what information do they want to see and what do they want to use PHRs for, and why (ie gain or benefit)? This understanding needs to include people who do not currently use PHRs and the requirements of different groups (eg adults, older people, children, people who are ‘hard to reach’, those with sensory and other disabilities and those with mental health issues, etc). Any study needs to examine requirements in a person-centred way across care setting boundaries, rather than from the perspective of specific care providers.
The categories of services provided currently by PHRs:
- communicating with your care team through the PHR
- seeing your medication records and tools, to review them and remind you to take medication
- services to help you to plan and manage your own care
- information and support services.
In the systems that were connected to the care providers’ EHR (17/23), 76% showed a benefit in the use of the PHR. However in standalone PHRs, benefits were seen only in 50% of the studies (3/6)
Responses about PHR services indicate that they are at a relatively low level of maturity.
- Most of the PHRs are currently setting-specific (ie primary, hospital or social care), although some suppliers have aspirations for integrated implementation across more than one setting.
- PHRs mainly provide patients with a view of their records, rather than the ability to update or annotate them, let alone upload their own data.
- Linkage of PHRs to electronic health or care record systems was in some cases aspirational, particularly when compared with implementer responses about current linkage. Also, the links are generally unidirectional (from the electronic health or care record to the PHR, rather than vice versa).
- The main way in which users could communicate with their care teams was via email-type messaging rather than instant methods, such as video and instant messaging etc.
- While PHRs enable patients or citizens to view their medications, they are generally setting- specific, for example only their GP or hospital medication records. Patients are unable to interact electronically with their medication record, eg to point out errors or to remind themselves to take their medicines.
The main use of PHRs is currently access to blood test results. In patient online access to GP records, repeat prescriptions and appointment booking are also major uses. PHRs tend to be used before or after appointments, which indicates that preparation for and debriefing on consultations is important. These uses are quite limited and, in the case of blood results, are limited to specific patient groups. There is still little evidence about how PHRs are used, what they are used for and why.
Potential benefits for both patients (improved experience and outcomes) and organisations (time, effectiveness and cost savings) were identified in the survey responses, but the majority were aspirational and we were able to obtain little supporting evidence of objectively realised benefits. The literature review identified a number of studies that identified patient benefits, but these were largely qualitative, focusing on how patients felt about the PHRs, rather than any quantitative assessment of their impact on health outcomes (eg lifestyle improvements) derived from bias-free study designs.
Similarly, reports of disbenefits were mainly related to fears and anxieties, for example of increased burden on clinicians or patient confidentiality, with little supporting evidence.[Top]