EHR-based Health Literacy Strategy to Promote Medication Therapy Management

描述(由申请人提供)：我们将评估两种以初级保健为基础的药物治疗管理策略，这两种策略利用电子健康记录在安全网诊所促进高血压和糖尿病患者对患者的理解、用药协调、用药依从性和疾病控制。患有多种慢性病的患者使用复杂的用药方案，然而许多人，特别是那些识字能力有限的人，在执行常规用药任务方面存在困难。随着Medicare Part D的推出，药物治疗管理(MTM)作为一项任务，帮助许多老年患者安全地使用他们的方案。根据目前的定义，MTM包括用药审查、个人用药记录的汇编、与用药相关的行动计划的制定和后续行动。然而，最初的MTM模型大多是在患者通常的护理来源(即药房)之外进行的。这可能会限制其有效性；与药物相关的问题将由临床医生讨论，而他们并不完全了解患者处方医生打算采用的方案。成本是MTM广泛使用的另一个障碍。我们的团队在一家学术内科诊所进行了现场测试，将各种低识字MTM工具嵌入到电子健康记录(EHR)中。在这项研究中，我们将这些工具结合在一起，以解决全面的MTM任务。总的来说，我们将其称为基于电子健康记录的健康素养药物治疗管理干预，或称“EHMI”。我们将评估EHMI策略的有效性，以提高1)患者对药物的了解，2)药物调整，3)坚持治疗方案，4)在联邦合格的健康中心(FQHC)接受治疗的高血压合并糖尿病患者的疾病控制。由于EHMI策略可能是足够的，我们也将评估纳入护士教育者，以帮助患者利用EHMI工具，提供简短的咨询，并跟踪进展。我们的具体目标是：1)测试EHMI策略的有效性，在有和没有护士教育人员的情况下，与常规护理相比，改善患者的理解、用药协调、依从性和健康结果；2)确定这些策略的效果是否因患者的识字技能而异；3)评估两种策略的保真度，并探索影响干预的患者、工作人员、医生和卫生系统因素；以及4)评估提供干预所需的成本，不包括系统设计。我们将在12家FQHC进行一项三臂临床随机试验来评估EHMI和EHMI+护士教育者的干预措施。糖尿病和未控制高血压的患者将在3个月、6个月和12个月时再次被招募和评估。我们还将评估干预措施的保真度和经济影响，为今后的传播工作提供信息。 公共卫生相关性：许多慢性病患者难以执行常规用药管理任务，特别是识字能力有限的个人，这可能导致危险的用药错误并危及治疗效果。总的研究目标是严格评估两种基于初级保健的药物治疗管理策略-一种使用护士教育人员，另一种不使用-利用电子健康记录来促进患者对如何使用药物的理解，减少用药差异，提高依从性，并改善安全网诊所高血压糖尿病患者的疾病控制。这里使用的基于EHR的工具可以广泛传播到使用商业EHR的其他网站，护士领导的干预结果将直接为临床护理团队的重新设计提供信息，以促进安全有效的用药。

DESCRIPTION (provided by applicant): We will evaluate two primary care-based, medication therapy management strategies that leverage an electronic health record to promote, patient understanding, medication reconciliation, medication adherence and disease control among hypertensive and diabetic patients at safety net clinics. Patients with multiple chronic illnesses use complex medication regimens, yet many, especially those with limited literacy, have difficulty performing routine medication tasks. Introduced with Medicare Part D, medication therapy management (MTM) serves as a mandate to help many older patients safely use their regimen. As currently defined, MTM includes medication review, assembly of a personal medication record, development of medication-related action plans, and follow-up. However, initial models of MTM have mostly been performed separate from patients' usual source of care (i.e. pharmacies). This may limit its effectiveness; medication- related concerns would be discussed by clinicians not fully aware of the regimen intended by the patients' prescribers. Cost is yet another barrier to widespread use of MTM. Our team has field tested at one academic internal medicine practice various low literacy MTM tools embedded within the electronic health record (EHR). For this study, we combine these tools to address a full range of MTM tasks. In aggregate, we refer to this as an Electronic health record-based Health literacy Medication therapy management Intervention, or 'EHMI'. We will evaluate the effectiveness of the EHMI strategy to improve 1) patient medication understanding, 2) medication reconciliation, 3) regimen adherence, and 4) disease control among hypertensive + diabetic patients treated in federally qualified health centers (FQHCs). As the EHMI strategy may or may not be sufficient, we will also evaluate the inclusion of a nurse educator to help patients utilize EHMI tools, provide brief counseling, and track progress. Our specific aims are to: 1) Test the effectiveness of the EHMI strategy, with and without a nurse educator, to improve patient understanding, medication reconciliation, adherence, and health outcomes compared to usual care, 2) Determine if the effects of these strategies vary by patients' literacy skills, 3) Evaluate the fidelity of the two strategies and explore patient, staff, physician, and health system factors influencing the intervention, and 4) Assess the costs required to deliver this intervention, exclusive of system design. We will conduct a three-arm, clinic-randomized trial at 12 FQHCs to evaluate the EHMI and EHMI + Nurse Educator interventions. Patients with diabetes and uncontrolled hypertension will be recruited and assessed again at 3, 6, and 12 months. We will also assess the fidelity and economic impact of the interventions to inform future dissemination efforts. PUBLIC HEALTH RELEVANCE: Many patients with chronic disease have difficulty performing routine medication management tasks, particularly individuals with limited literacy, and this can cause dangerous medication errors and jeopardize treatment efficacy. The overall study objective is to rigorously evaluate two primary care-based medication therapy management strategies-one using a nurse educator and one without-that leverage an electronic health record to promote patient understanding of how to use medications, reduce medication discrepancies, improve adherence and improve disease control among hypertensive diabetic patients at safety net clinics. The EHR-based tools used here could be widely disseminated to other sites that use commercial EHRs, and the results of the nurse-led intervention will directly inform clinic care team redesign to promote safe and effective medication use.