The PHIMed Study: A mixed methods study of how patients, carers and - - PowerPoint PPT Presentation

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The PHIMed Study: A mixed methods study

• f how patients, carers and healthcare

professionals use Patient Held Information about Medicines

Dr Sara Garfield Prof Bryony Dean Franklin

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BACKGROUND

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Medication safety

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Errors at transitions of care

• 60% of patients admitted to hospital have at least
• ne discrepancy on their admission drug history.
• National Reporting and Learning System for

England and Wales: 7,070 medication errors involving admission and discharge with 2 fatalities and 30 severe harm reported in 2007.

• 113 London GPs: addressing incomplete

reconciliation of medication is the highest priority in improving medication safety.

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The WHO response to medication errors

• Third global challenge 2017:

“Medication without harm”

• Aim to reduce severe

avoidable harm related to medications by 50% over 5 years, globally

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The WHO response

• Four domains:

– patients and public – healthcare professionals – systems and practices – medicines

• Early priority actions to focus on three areas:

– transitions of care – high-risk patients and situations – polypharmacy

• Revision of Medication Safety Curriculum Guide

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The English response

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Short life working group recommendations:

• Better linking of primary care and secondary care data to

identify medication-related hospital admissions

• Focus on patient-friendly packaging and labelling
• Accelerating the introduction of hospital electronic

prescribing systems

• Greater patient involvement
• Development of a repository of good practice

NHS England Patient Safety Strategy:

• Greater involvement of patients, carers and the public

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Self Care Agenda

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Background to PHIMed study

• Risks of poor information transfer

– Medication a particular issue

• Importance of patients as active

partners in healthcare

• Various types of patient held

information about medicines (“PHIMed”)

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Research question

• What should healthcare

professionals be recommending in relation to PHIMed?”

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Theoretical framework: Distributed cognition

• Distributed cognition – useful for

understanding systems that involve information being shared across people, tools and artefacts

• Distributed Cognition for Teams (DiCoT)
• facilitates application of distributed

cognition by considering: different information flows in the system, the influence of people, how design of tools and artefacts helps or hinders, how information is processed over physical spaces, and how information processing evolves over time.

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METHODS

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Overview of methods

• Five work packages (WP)
• WP0: preparation: ethics and literature review
• WP1: interviews and focus groups
• WP2: documentary analysis of how PHIMed used
• WP3: descriptive analysis of PHIMed solutions
• WP4: triangulation and integration of findings to

create recommendations for practice and next steps

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WP 1: Qualitative interviews & focus groups

• Two focus groups with

patients and carers, including users and non-users of PHIMed

• Interviews with 16 healthcare

professionals

• Explored the roles of

PHIMed, key features, barriers and facilitators to its use, and unintended consequences

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WP 2: Documentary analysis

• Recruitment of sample of 60 PHIMed users.

Documentary analysis of how PHIMed had been used, what has been documented and read, and by whom, over last three months. Questions around how often carried, how up to date it is, why used, and if and how integrated with other information such as summary care record.

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WP 3: Analysis of PHIMed features

• Descriptive analysis of PHIMed solutions used /

available in the UK, both electronic and paper, and categorising their design and key features based on those identified in WP1 and WP2

• Usability testing

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WP 4: Integration and analysis

Findings from WPs 1-3 integrated and analysed to explore how information is recorded, used and transformed among different people and artefacts

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FINDINGS

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WP1 Participants

• WP1 focus groups

– 4 males, 12 females – 7 patients, 6 carers, 3 both patients and carers – 12 PHIMed users, 5 non-PHIMed users

• WP1 healthcare professional interviews

– 2 GPs, 2 practice nurses, 2 community pharmacists, 2 community opticians, 2 dentists, 2 hospital doctors, 2 hospital nurses, 2 hospital pharmacists. – 7 males, 9 females

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WP2 participants

• 60 PHIMed users in total
• 23 male and 37 female
• Different types of PHIMed / use of PHIMed:

– 15 basic paper users – 15 extensive paper users – 15 basic digital users – 15 extensive digital users

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WP3: PHIMed tools

103 PHIMed tools assessed:

• 57 digital apps
• 42 paper-based tools
• 4 websites

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Findings: Experience of PHIMed

• Patients’ and healthcare professionals’

experiences of PHIMed were mostly positive.

– ‘It’s mainly been of surprise that someone has given them a concise, easy to read list being truthful. They can’t believe their luck’ (focus group 1 participant) – ‘I’m always really positive. I’ve always been very pleasantly surprised if they bring it with them, it makes my job a lot easier if they bring it’ (hospital doctor 1)

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How does PHIMed enhance safety?

• Creates the ‘glue’ between a disjointed

healthcare system.

• Enhances situation awareness
• Error checking
• Ease of communication
• Patient empowerment
• Aide memoire during appointments
• Reminder to take
• Reminder to reorder

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Findings: Specific examples positive

• utcomes of PHIMed use
• Use of PHIMed during emergency admissions
• f patients or family members
• Identifying medicines that would have

interacted with what another prescriber would have given

• Dealing with medication-related issues when

abroad

• Identifying an adverse drug reaction

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Findings: Some negative experiences

• 'They see what you are on and think you are a

trouble case.' (PHIMed user 9)

• An ‘old school’ consultant wasn’t satisfied with

seeing the prescription list. He said “No, no, no I like to see the actual boxes what the instructions tell you to do” (focus group 1)’

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Findings: Barriers

• Many patients had not considered using a hand-

held record to help communicate their medicines to healthcare professionals. They thought information would be automatically transferred.

• Some people carried extensive information about

their medicines but did not share this information at appointments as they were not asked about their medicines.

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Triggers to using PHIMed

• PHIMed study:

– ‘I always assumed the hospitals would know so I think I’ll have to get a repeat prescription and just keep that

• n me.’ (focus group 2 participant)

– ‘Maybe I should have something about it, I don’t know. Yes, it’s [the PHIMed study] made me think twice about it, I must say’ (focus group 2 participant).

• Complexity
• Concerns about emergencies
• Encouragement by healthcare professionals or

friends/family

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Findings: diversity

• Type of PHIMed used:

– Paper vs digital – Pre defined tool vs patient created

• Purpose for which PHIMed is used:

– In case of emergency – General communication with healthcare professionals – Other uses

• The way in which PHIMed is used:

– Aide memoire – Shown to healthcare professionals

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Findings: Paper vs digital tools

Paper

• Does not require

smartphone ownership.

• Is always customisable
• Is always editable
• Can be easier to access
• Does not rely on Wifi or

charged batteries.

• May be more likely to

show medication history

• Is easier to hand over to
• thers

Digital

• Is always with the patient
• Does not become ripped
• r torn.
• Is easily updated
• Improved legibility
• Can include reminders to

take and order medicines.

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Findings: PHIMed tools

• No tools had all the 11 core features

identified from work packages 1 and 2.

• Only a minority of tools had fields for

indication/purpose of medicine and

• allergies. However, these were both

considered important by healthcare professionals.

• Few patients included indication as they

thought healthcare professionals would know what their medicines would be for.

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Examples of paper-based tools

• FP10/ hospital communications
• My Medication Passport
• Allergy plan
• Parkinson’s Disease card
• Medic alert
• List of medicines on a “Post-it” note
• Printed list of medicines
• Diary of medicines

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Examples of digital tools

• iPhone health app

– Comes as standard on iPhone – A list of medicines can be produced in a free text box as part of a “medical ID” – There is an option for users to allow access to this in an emergency without needing to input phone password or fingerprint – This use of the app is not obvious from its front page

• Medisafe app
• Medicines as a “contact” in contacts list
• Digital notepads

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Standard vs patient-created

• Standard

– Easily recognised by all in an emergency – Healthcare professionals more likely to take ownership

• Patient created

– More customisable – Patient more likely to take ownership

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Who should update?

Patients

• Completeness/empowerment

‘It’s no good saying a healthcare professional because they could be under the administrations of more than one healthcare professional. Each doctor, nurse or pharmacist that you are dealing with may well

• nly have a partial set of

information about you. You’re the

• nly person who’s got every bit of

information.’ (focus group 1)

Healthcare professionals

• Accuracy/trust

‘I personally think it should be the … medical staff purely because I think if you’re asking the patient to change it then let’s supposing accidentally they change it to the wrong …. I think it would be more sensible that the changes are made by somebody who is clinical and clearly the records should specify he’s made the change.’ (GP 1)

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Over the counter medication

• ‘I can’t recall an MUR [medicines use review] where it’s

something that they’re taking over the counter has alerted me to a problem.’ (community pharmacist 1)

• ‘If they’ve been taking lots of ibuprofen then if they

come in with a suspected perforated ulcer then I need to know, because that’s a risk factor.’ (hospital pharmacist 1)

• ‘I assume they’re [prescription medicines] more

powerful, more likely to cause side effects [than OTCs] and that’s why they’re prescription only.’ (community

• ptician 1)

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RECOMMENDATIONS AND NEXT STEPS

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• Encourage your patients and their carers to carry

PHIMed

• Remember one size doesn’t fit all – different

tools work for different people

• Ask patients / carers if they carry PHIMed. Ask to

see it in consultations and show them that you value this

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Next steps

• Cluster RCT of PHIMed awareness campaign in

hospitals

• Effects on patient activation and medication errors

across settings

• ? Post myocardial infarction patients

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Potential intervention components

• Leaflets, posters and videos
• Incorporation of discussions about PHIMed into

routine outpatient appointments e.g. post MI check ups

• A learning portal with questions
• Encouraging healthcare professionals to show

patients that they value PHIMed

• PHIMed patient champions
• Flexibility for sites to adapt the intervention to

work for them.

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Questions