Title: The ElPresMO Sudy - Electronic Prescribing and Medicines Optimisation in the hospital setting: What helps and hinders the patient conversation?
Funder: Health Education England

Abstract: Background The benefits of digital systems in healthcare are well established, but there can be unintended consequences for patient care. Before digitalisation, medication-related tasks were often performed using the paper prescription chart kept at the patient bedside, allowing patients and staff the opportunity to discuss medicines. Electronic Prescribing (EP) systems have changed staff behaviour as they enable medication-related tasks to be undertaken away from the bedside, reducing opportunities for patients to talk about medicines, with negative impacts on medication adherence and patient outcomes. Medicines Optimisation (MO) is the recommended approach where understanding medicines use from the patient's perspective is central. It is considered fundamental to better use of medicines and reducing medication errors, and depends on healthcare professionals (HCP) communicating with patients. Research is needed to understand the circumstances and behaviours that best support conversations between patients and their healthcare providers about medicines when using EP systems. Research Question The ElPresMo Study - Electronic Prescribing and Medicines Optimisation in the hospital setting: What helps and hinders the patient conversation? Aims and Objectives Aim: To determine what supports and constrains patient involvement in MO in the hospital setting, when using EP.Objectives: 1. To undertake a realist review of the literature on patient-HCP staff interaction in the context of MO when using EP systems. 2. To identify in what contexts, and for whom, EP systems affect the patient and HCP communication about medicines. 3. To develop recommendations that best support patient involvement in discussions about medicines as part of the MO approach when using EP systems. Methods and timelines Work Package 1, in year 1: A realist review, incorporating a behaviour change model, to develop a theory of what supports and constrains patient engagement as part of the MO approach in the hospital setting, when using EP systems.Work package 2, in year 2: A multi-site observational case study using ethnography, interviews and quantitative data in two different ward environments, in two different hospitals. This information will refine and add to the theory developed in work package 1.Work package 3, in year 3: In the first 6 months, translation of the evidence-based refined theory into recommendations that will support best practice for MO with EP systems in the hospital setting. The last 6 months will be dedicated to writing up, and dissemination of, research findings. Anticipated impact and dissemination Research findings will be published in peer reviewed international journals and presented at regional, national and/or international conferences. The results will be shared with patients and the public through social media, animated videos, written summaries, e.g., patient newsletters and oral presentations. The recommendations will be based on theory and an understanding of practice, and will likely contain elements of model behaviours and principles to best support the patient-HCP conversation as part of MO. Recommendations will inform post-doctoral work including the design and evaluation of an intervention, with an anticipated feasibility study. This will provide the basis for a definitive trial regarding the impact of the intervention on MO and patient outcomes.

Lay abstract: Background As a hospital pharmacist, I arrived on the ward to find a trainee pharmacist Jo, sitting at a computer in the doctor's office. Logging onto the computer, Jo talked me through our first patient Sarah who had been in hospital for six weeks with a wound infection. Sarah has diabetes for which she takes tablets, and has had multiple surgical procedures on her wound during this admission. We studied Sarah's electronic medical notes, blood results and observations as we reviewed the medicines on the electronic prescription chart. Jo asked if she should set the next medication review for three days' time. I suggested we speak to Sarah first. Jo looked puzzled, 'why are we going to see her, what are you going to ask?'.During our conversation, Sarah explained how she struggled to swallow her tablets, especially the diabetes one, because repeated anaesthetic had made her mouth and throat dry. We discussed and arranged treatment for this, then changed her medicines making them easier to swallow. Sarah asked if one of her longer-term tablets could stop? I explained it was safer to stay on it for now, but suggested a GP review and gave Sarah information about when and who to discuss this with. As we left Sarah's bedside Jo said 'I wasn't expecting that. That really changed what we have done for that patient'. Multiple healthcare staff contribute to medication-related decisions. Electronic prescribing systems enable staff to prescribe and record when medicines are given using a computer, and use in hospitals continues to grow. Before these systems, healthcare staff would visit the bedside to access the prescription chart providing opportunities to talk about medicines. Government policy describes patient involvement in discussions and decisions about medicines as an approach to improving patient care, yet clinical practice and research shows electronic prescribing systems reduce contact between patients and their healthcare teams by enabling access to the prescription chart away from the bedside, causing medication errors and poorer patient care. Aim To determine what helps and hinders the patient conversation with the healthcare team about medicines, as part of the approach to improving patient care, when using Electronic Prescribing systems in hospital.Research Plan This research will be in three parts. Part one will identify ideas from research articles that describe the circumstances and behaviours that support patient conversations about medicines when using Electronic Prescribing systems. Part two will involve observing and interviewing hospital staff and patients on two hospital sites, when undertaking medication-related activities with Electronic Prescribing systems. This information will refine the ideas from Part one. Part three will translate the ideas into recommendations to support best practice for improving medication-related care when using Electronic Prescribing systems in hospital. Patient, Carer and Public involvement (PCPI) and engagementPCPI has been central in developing this application. PCPI workshops with 14 group members, and 4 interviews, were undertaken. Discussions informed research focus and design, and provided feedback on the Plain English Summary, patient involvement, and sharing research findings. Patients will be involved throughout this research as panel members who will: attend progress meetings, review patient information literature, contribute to creating the ideas in part 1, give feedback on interview questions, analyse interview recordings in part 2, contribute to translating ideas to recommendations in part 3, contribute to writing articles and presenting the results.Dissemination Research findings will be published in international peer reviewed journals and presented at regional, national and/or international conferences. The results will be shared with patients and the public using written word, oral presentation and animation videos on social media, and in written summaries such as patient newsletters.

Research activity codes: 7.1 INDIVIDUAL CARE NEEDS;8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE