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IIR 14-059 – HSR&D Study

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IIR 14-059
The Secure Messaging for Medication Reconciliation Tool (SMMRT) Trial
Steven R Simon MD MPH BS
VA Boston Healthcare System Jamaica Plain Campus, Jamaica Plain, MA
Boston, MA
Funding Period: July 2015 - September 2019

BACKGROUND/RATIONALE:
Resolving medication discrepancies - i.e., medication reconciliation - is mandated at every care transition, but little is known about intervention strategies to improve medication reconciliation in the post-discharge period, when patients may lack prompt access to primary care and are at high risk for ADEs. To address this gap, we developed and pilot tested the Secure Messaging for Medication Reconciliation Tool (SMMRT), with a pharmacist communicating with Veterans to review medications and reconcile discrepancies after hospital discharge via Secure Messaging (SM), within My HealtheVet (MHV), VA's patient portal. Our pilot study detected, on average, two clinically important medication discrepancies per Veteran immediately following discharge and demonstrated that Veterans could interact with the pharmacist asynchronously to resolve discrepancies. Veterans found SMMRT easy to use and indicated they would willingly use it again.

OBJECTIVE(S):
Aim 1. To conduct a formal usability assessment of SMMRT and improve usability for Veterans, pharmacists and nurses.

Aim 2. To conduct a 2-arm RCT to evaluate the effects of SMMRT, randomizing 240 hospitalized Veterans to compare 1) Usual Care 2) Usual Care + SMMRT after discharge.

Aim 3. Formative evaluation of the intervention for potential future implementation, with qualitative analysis of in-depth interviews from among 20 Veterans and 10-15 primary care nurses and 5-10 pharmacists.

METHODS:
The study has three specific aims:
Aim 1. To conduct a formal usability assessment of SMMRT and improve usability for Veterans,
pharmacists and nurses. Although SMMRT has been pilot tested among 60 Veterans, the tool's graphical user interface (what the user sees on the screen) has since been enhanced. Focused usability testing will allow refinement of the tool for optimal Veteran, pharmacist and nurse acceptability and potential effectiveness.

Aim 2. To conduct a two-arm RCT to evaluate the effects of SMMRT. Veterans successfully recruited and consented to participate will be randomly allocated to either UC or UC+SMMRT. Veterans randomized to UC+SMMRT will receive introduction to My HealtheVet and SMMRT. Within 3 days of discharge, the SMMRT Research Pharmacist will engage with Veterans and/or their designated family members to conduct medication review and reconciliation. The primary outcome measure will be medication discrepancies detected 30 days after discharge. Secondary outcome measures will be 30-day hospital utilization (combined readmissions plus emergency department use) and Veterans' self-efficacy in medication use.

Aim 3. To evaluate MHV training and SMMRT interventions for potential future implementation. In anticipation of future implementation, we will use qualitative methods to identify features of the interventions that are most and least effective, as well as elements most and least likely to be accepted into clinical practice.

FINDINGS/RESULTS:
Aim 1. Data collection and analyses are complete. Two manuscripts accepted for publication. This Aim was carried out as follows. The prototype SMMRT tool was refined through iteration among the expanded investigator team. After refinement, the tool was subjected to formal, structured usability testing, first with providers and then with patients. A total of 20 Clinical Providers and 10 Veteran Patients participated in structured usability testing. Key usability errors identified among providers were (1) difficulty sending attachments in the Secure Messaging System and (2) frustration with the lack of integration between the SMMRT tool, Secure Messaging/My HealtheVet, and the CPRS medical record. Among patients, the two most frequently noted usability errors were (1) difficulty navigating to the secure messaging portal from the My HealtheVet website and (2) difficulty opening the attachment file (containing the SMMRT tool). The usability testing assessed efficiency and task completion times. For Veteran patients, the median time to open the secure message was slightly greater than 5 minutes, with a range of 2 to 15 minutes. For Veterans, the median time required to send the secure message with the SMMRT tool attached was just over 6 minutes, compared to just under 5 minutes for the providers. Participants generally agreed favorably with statements regarding system usefulness, information quality, interface quality and overall satisfaction. Veteran patients' levels of satisfaction showed marked improvements in the second wave of testing, following substantial changes to the SMMRT tool that were based on input and observations from the first wave of participants.

Aim 2 and 3 do not have findings to date.

IMPACT:
Aim 1. The usability testing led to substantial improvements in the format and content of the SMMRT tool. These changes are being incorporated into the Aim 2 intervention trial, along with efforts to mitigate the challenges that both Veterans and Clinical Providers described regarding the native electronic systems.

Aim 2 will test the effectiveness of the SMMRT tool. Aim 3 will assess the potential for wider implementation. If proven effective, SMMRT will have several impacts on Veterans and their health care: 1) decreased medication discrepancies; 2) decreased emergency room visits and hospital readmissions; and 3)improved patient-engagement, patient-centeredness, and patient satisfaction.

PUBLICATIONS:

VA Cyberseminars

  1. Russ AL. Usability Evaluation of the Secure Messaging for Medication Reconciliation (SMMRT) Tool. VIReC Clinical Informatics Seminar [Cyberseminar]. Health Services Research and Development. 2016 Jul 19.
Conference Presentations

  1. Jahn MA, Caldwell BS, Nguyen KA, Patel H, Simon SR, Zillich AJ, Russ AL. Improving Patient – Provider Communication for Medications via Health Information Technology. Poster session presented at: Purdue Industrial Engineering Graduate Student Organization Annual Research Symposium; 2016 Apr 21; West Lafayette, IN.


DRA: Health Systems, Other Conditions
DRE: Treatment - Observational, Technology Development and Assessment
Keywords: Electronic Health Record, Medication Management, Outcomes - Patient, Patient Safety, Personal Health Record, Pharmacology
MeSH Terms: none