Feasibility of an electronic health record web‐based application to optimize medication‐related communication between skilled home healthcare clinicians and primary care providers

Substantial barriers to effective communication exist between skilled home healthcare (SHHC) clinicians and primary care providers [PCPs (physicians or advanced practice providers)]1-4 including lack of interoperability across electronic health record (EHR) systems and difficulty in coordinating communication among care providers, especially around medication management.5 To ameliorate these barriers, we developed the HOME Tool (HT), a web-based application that automatically leverages EHR data to assist medication reconciliation and improve communication around medication management during an SHHC episode.6 The HT also allows SHHC clinicians to alert primary care providers to clinical issues via a “clinical insights” feature. We report on an HT feasibility and usability pilot to improve communication on medication-related issues during an SHHC episode between patients, PCPs, and SHHC clinicians. A pilot study was conducted for 10 SHHC episodes ordered by three Johns Hopkins (JH) home-based primary care or ambulatory physicians (PCPs), and four SHHC clinicians (three nurses and one physical therapist). Over 3.5 years the HT was iterated, adapted, and integrated to work within patient encounters of the JH EPIC EHR. During integration, we discovered a generalized medication-related safety issue for the JH EPIC system that went beyond the functionality of the HOME Tool. EPIC was sometimes unable to parse non-discrete medication order data from outside pharmacies, requiring clinicians to reenter dose and schedule for refills. Correcting this issue for JH clinicians, in general, and for the HT, in particular, required creation of look-up tables by the JH EPIC team to harmonize data from pharmacies outside of our hospital system with EPIC. These tables resolved about 50% of the data issues. Thus, to ensure medication data accuracy during the pilot, PCPs and SHHC clinicians accessed the HT application within EPIC, reviewed and modified the medication schedule as needed, and verified the accuracy of the printed copy of the HT given to patients and their care partners. Prior to patient enrollment, eligible PCPs and SHHC clinicians completed a 30-min live virtual HT training or viewed a recorded version of the training. We tested feasibility of the HT through automated data extraction methods that pulled medication data directly from the EPIC EMR to populate two versions of the HT (Figure 1), one for communication with the patient and family, and one for communication between the SHHC clinician and the PCP. We also conducted exploratory analysis to assess usability with a modified version of the System Usability Scale (SUS) tailored for patients, SHHC clinicians, and PCPs. The JHMI Institutional Review Board approved the study. The HT was successfully generated in the EPIC EHR and printed for all 10 patients. Mean age of patients was 81.4 years (SD 9.3) and 50% were female. Mean number of medications per SHHC episode was 12.4 (SD 4.9) and the mean Medication Regimen Complexity Score7, 8 was 31.4 (SD 10.7). All medications were successfully extracted from EPIC to populate the HT without error. SHHC clinicians made changes to the medication list following complete medication reconciliation in the patients' home. Medication schedules were accurately populated in the HT to indicate when patients should take their medications. SHHC clinicians utilized the insights section of the HT to communicate with PCPs in one of 10 cases. Surveyed SHHC clinicians (n = 4) reported on scale of 1 to 4 (1 = strongly disagree, 4 = strongly agree), the HT was easy to use (4/4, 100%), and that they would use it frequently (4/4, 100%). Limited data are available for PCPs and patients and caregivers with too few responses to draw conclusions. The small pilot of the HT in the EPIC EHR demonstrated that the HT extracted all medication-related data from the EHR without error and was feasible to access and use in the EPIC EHR. SHHC clinicians positively rated the HT's ease of usability and reported they would use the tool frequently during an SHHC episode. Feedback from PCPs and patients around usability was lacking and is needed to better understand the effectiveness of the tool. Creating the HT within the JH EPIC EHR unveiled significant JH system-wide medication issues with outside pharmacies sending refill requests without discrete fields that required substantial effort to resolve, making it more challenging to automate the population of the medication data safely. It is not well known if this medication data issue persists in other health systems using EPIC EHRs and is an area to further investigate. Future work should consider the substantial challenges of integrating and implementing programs such as the HT or similar applications into the EPIC EHR. Overcoming communication barriers in SHHC due to lack of interoperability between EHRs may require dedicated IT resources and partnerships with many stakeholders including and not limited to EHR systems. Jonathan D. Norton: Study concept and design, Acquisition of data/subjects, Analysis and interpretation of data, Preparation of manuscript. Kimberly Carl: Study concept and design, Analysis and interpretation of data, Preparation of manuscript. Adeola Alowonle: Study concept and design, Acquisition of data/subjects, Preparation of manuscript. Bruce Leff: Study concept and design, Acquisition of data/subjects, Analysis and interpretation of data, Preparation of manuscript. Orla C. Sheehan: Study concept and design, Acquisition of data/subjects, Analysis and interpretation of data, Preparation of manuscript. Cynthia M. Boyd: Study concept and design, Acquisition of data/subjects, Analysis and interpretation of data, Preparation of manuscript. The authors thank the Johns Hopkins Home Care Group and clinicians for participating in this project. We would also like to acknowledge the work of the Johns Hopkins Technology Innovation Center on the HOME Tool. Dr. Boyd, Dr. Leff, and Dr. Sheehan are developers of the HOME Tool, an electronic health record embedded tool to enhance communication between skilled home healthcare clinicians and physicians. The HOME Tool is registered as a Johns Hopkins invention through the Johns Hopkins Office of Tech Ventures. Dr. Leff serves as a volunteer board member of the Alliance for Home Health Quality and Innovation. Dr. Boyd is coauthor of a chapter in Uptodate on multimorbidity. All other authors have no conflicts to disclose. The sponsor had no role in the design, methods, subject recruitment, data, collections, analysis, and preparation of the article. Johns Hopkins School of Medicine Discovery Fund Synergy Award. Johns Hopkins University Edward R. Roybal Center for Translation Research of the National Institute on Aging (NIA) under award number P30AG048773. In addition, Dr. Boyd and Jonathan Norton were supported by the National Institute on Aging, award number K24AG056578 (Boyd).