Principal Investigator: Mr. Tim Delaney
Research title: A rapid realist review of the Need, Design, Use and Implementation of Electronic Medication Databases in Clinical Practice at Care Transitions
Meath Foundation research funding awarded 2019
A research project which identified ten theories about ways to impact on the successful design, development and use of personal electronic records of medications (PERMs) at care transitions for medication reconciliation (MedRec), was presented to the symposium by Tamasine Grimes, Associate Professor, Practice of Pharmacy, at TCD.
Dr. Grimes presented the paper on “Personal Electronic Records of Medications (PERMs) for medication reconciliation at care transitions: a rapid realist review,” on behalf of Mr. Tim Delaney, Chief Pharmacist, Tallaght University Hospital.
The project was funded by a Research Grant from the Meath Foundation and has been published.*
Prof. Grimes said lack of access to accurate information on patients’ medicine use at admission to or discharge from hospital increased the risk of medication errors. Medicine-related problems (MRP) such as side effects, inappropriate use and errors were a serious threat to patient safety. MRPs reduced quality of life, cause morbidity, death and increase health care costs.
Medication reconciliation (MedRec) a programme to reduce medication error was resource intensive and time consuming, and one reason for this was that information from inside and outside the hospital, e.g. from the primary care team, was not joined up and the computer systems did not speak to each other.
“There have been repeated calls for integration of health information systems, including what we have termed Personal Electronic Records of Medications (PERMs) across sectors of care and between Healthcare practitioners to facilitate MedRec.
“The use of Personal Electronic Records of Medications (PERMs) in health information systems to support MedRec have proven challenging. Relatively little is known about the design, use or implementation of PERMs at care transitions that impacts on MedRec in the ‘real world’.
“To respond to this gap in knowledge we undertook a rapid realist review to develop theories to explain how, why, when, where and for whom PERMs were designed, implemented or used in practice at care transitions that impacted on MedRec.”
A rapid realist review is a systematic, scientific way to gather relevant studies and papers, find critical pieces of information in them and formulate them into theoretical statements, i.e. if we do “this”, then “that” will happen. The approach takes advantage of both academic expertise in the field, through an expert panel, and stakeholders on the ground who have experience of the issue being studied, i.e. the reference panel, to support refinement of the theories. They undertook their rapid realist review over a seven-month period from August 2020 to February 2021.
A Reference Panel was made up of thirteen key stakeholders, providing insight from clinicians, safety science, informatics, human factors expertise, e-health, governance, policy, research and academia. The Expert Panel consisted of five key researchers in the area, from Ireland, the UK, Sweden and the USA.
They examined nineteen articles published between 2006 and 2020. These covered the design, implementation and use of PERMs in the UK, Australia, Austria, Belgium, Canada, Denmark, Sweden and the US. These studies reported on the use of local PERMs in a hospital or clinic setting, national PERMs, on patients’ use of PERMS, on an electronic discharge system and an e-messaging system.
The users of the PERMs were predominately hospital-based staff but they also included GPs, community pharmacists, nursing home staff, and users who were patients, their families or carers.
She said the review enabled the team to develop ten theories proposing ways that the success of the design of these electronic systems, their implementation into a clinical setting and their routine use in clinical practice, could be enhanced. In simple terms, these theories presented hints and tips that could be used by vendors, government departments, healthcare organisations or individual practitioners or researchers to support the successful design, development or use of these systems. Examples of the theories included: engaging all stakeholders, allowing a free flow of ideas and feedback to support continuous learning and system improvement; building trust in relation to the accuracy, safety and security of the data; providing sufficient resources for the full potential of PERMs to be realised; considering interoperability; and valuing and supporting the patients having a role in using PERMs for MedRec.
Providing further detail on two of the ten theories, Prof. Grimes explained that if PERMs were designed with user input and employed user-centred design and usability principles, then users would feel heard and supported, thus fostering successful collaboration, acceptance and increased use of PERMs to complete MedRec at care transitions. If the increased effort and the value of using these systems as a means to provide opportunities for risk identification, management and analysis, was recognised by leaders/management from the outset then they would understand the need for additional resourcing to support the use of PERMs to improve MedRec at care transitions and patient safety.
She said these theories were available to incorporate into future interventions to enhance medication safety at care transitions, or to map to existing interventions to help us understand better why they worked, or not. As with all theories, they might also be evaluated to further test their validity and refined or rejected based on that evaluation.
Those who participated in the project were, Catherine Waldron, Joan Cahill, Sam Cromie, Tim Delaney, Sean P. Kennelly, Joshua M. Pevnick & Tamasine Grimes. She also wished to acknowledge Jack Kavanagh and Aaron Koay who undertook some preliminary work for this project in 2018. They were grateful for the assistance of the information specialists in Trinity College Dublin, Andrew Jones and Caitriona Honohan, who supported the development of the electronic search strategies, the Reference Panel, Roisin Adams, Dan Burns, Tim Delaney, Jane Kenny, Ciara Kirke, Rosa McNamara, Louise McQuaid, Kevin O’Carroll, Neil O’Hare, Muriel Pate and Alan Reilly and the Expert Panel, comprising the research team and Tora Hammar, Patrick Redmond and Ann Slee.
*Waldron, C., Cahill, J., Cromie, S. et al. Personal Electronic Records of Medications (PERMs) for medication reconciliation at care transitions: a rapid realist review. BMC Med Inform Decis Mak 21, 307 (2021). https://doi.org/10.1186/s12911-021-01659-8