JMIR Publications

ABSTRACT

Background:

Poor data transfer between electronic health record (EHR) systems has been a challenge hindering availability and usability of patient information in clinical practice and evidence-based decision making. To improve data transfer, patient information should be documented in a structured format. This also applies to medication-related patient information and results of the interventions, such as medication reviews (MRs), to individually optimize medication regimens, especially in older adults.

Objective:

The aim of this study was to identify what information obtained from MRs should be documented in a structured form in EHRs at a national and organizational level.

Methods:

The study was conducted as a three-round Delphi consensus survey in 2020. The electronic survey was based on a comprehensive inventory of international and national MR procedures in various settings. Expert panelists (n=41) independently assessed which topics should be documented in a structured form in EHRs. The interprofessional panel (n=41) consisted of 12 physicians, 13 pharmacists, 10 nurses, and six information management professionals (participation rate 66-76% in rounds 1-3, consensus limit set at 80%). The responses were analyzed quantitatively and qualitatively.

Results:

Consensus was reached on 108/111 of predetermined topics to be documented in a structured form in EHRs. Of them, 39 concerned the MR process, 25 potentially drug-induced symptoms, 11 burden of risks for adverse drug effects, 12 laboratory tests and other test results, 12 medication adherence and nine use of intoxicants. The patient’s blood pressure (mean 4.85±0.53 on a Likert scale 1–5), kidney function (4.81±0.56) and risk of bleeding (4.81±0.56) were ranked as the three most important topics to be documented in a structured form. The panel reached a consensus that the information obtained from MRs should be made available to all healthcare professionals in the national digital repository for patient data and to patients to some extent.

Conclusions:

The interprofessional expert panel strongly agreed on the results of the MRs that should be documented in a structured form in EHRs and made available both to health professionals involved in care teams and to patients themselves.