Leah M. Haverhals

Older adults with multi-morbidity: medication management processes and design implications for personal health applications.

Background Older adults often have multiple chronic problems requiring them to manage complex medication regimens overseen by various clinicians. Personal health applications (PHAs) show promise assisting in medication self-management, but adoption of new computer technologies by this population is challenging. Optimizing the utility of PHAs requires a thorough understanding of older adults’ needs, preferences, and practices. Objective The objective of our study was to understand the medication self-management issues faced by older adults and caregivers that can be addressed by an electronic PHA. Methods We conducted a qualitative analysis of a series of individual and group semistructured interviews with participants who were identified through purposive sampling. Results We interviewed 32 adult patients and 2 adult family caregivers. We identified 5 core themes regarding medication self-management challenges: seeking reliable medication information, maintaining autonomy in medication treatment decisions, worrying about taking too many medications, reconciling information discrepancies between allopathic and alternative medical therapies, and tracking and coordinating health information between multiple providers. Conclusions This study provides insights into the latent concerns and challenges faced by older adults and caregivers in managing medications. The results suggest that PHAs should have the following features to accommodate the management strategies and information preferences of this population: (1) provide links to authoritative and reliable information on side effects, drug interactions, and other medication-related concerns in a way that is clear, concise, and easy to navigate, (2) facilitate communication between patients and doctors and pharmacists through electronic messaging and health information exchange, and (3) provide patients the ability to selectively disclose medication information to different clinicians.

Designing a personal health application for older adults to manage medications

Older adults with multiple chronic conditions are prone to care transitions, such as seeing a new doctor or being discharged after a prolonged hospital stay. These transitions are often uncoordinated and can imperil patients by omitted, duplicative, or contradictory treatment plans. We developed an open source, web-based Personal Health Application (PHA) using an iterative participatory design process that provides older adults and their caregivers the ability to manage their personal health information during care transitions. We report our findings from six user studies that establish the imperative need for interdisciplinary research and collaboration among all stakeholders - patients, caregivers, health professionals, designers, and health informaticians - to create effective PHAs. We conclude with design guidelines that encourage researchers to gradually increase functionality as users become more proficient interacting with the PHA.

Colorado Care Tablet: The design of an interoperable Personal Health Application to help older adults with multimorbidity manage their medications

Medication errors are common and cause serious health issues during care transitions, particularly for older adults with multiple chronic conditions. In this paper, we discuss the design and evaluation of the Colorado Care Tablet, a Personal Health Application (PHA) that helps older adults and their lay caregivers manage their medication regimes during care transitions. We created a PHA that older adults with limited computing experience could easily use by designing an application based on their real world artifacts and workflows.

Cardiovascular Events Are Not Associated with MTHFR Polymorphisms, But Are Associated with Methotrexate Use and Traditional Risk Factors in US Veterans with Rheumatoid Arthritis

Objective. C677T and A1298C polymorphisms in the enzyme methylenetetrahydrofolate reductase (MTHFR) have been associated with increased cardiovascular (CV) events in non-rheumatoid arthritis (RA) populations. We investigated potential associations of MTHFR polymorphisms and use of methotrexate (MTX) with time-to-CV event in data from the Veterans Affairs Rheumatoid Arthritis (VARA) registry. Methods. VARA participants were genotyped for MTHFR polymorphisms. Variables included demographic information, baseline comorbidities, RA duration, autoantibody status, and disease activity. Patients’ comorbidities and outcome variables were defined using International Classification of Diseases-9 and Current Procedural Terminology codes. The combined CV event outcome included myocardial infarction (MI), percutaneous coronary intervention, coronary artery bypass graft surgery, and stroke. Cox proportional hazards regression was used to model the time-to-CV event. Results. Data were available for 1047 subjects. Post-enrollment CV events occurred in 97 patients (9.26%). Although there was a trend toward reduced risk of CV events, MTHFR polymorphisms were not significantly associated with time-to-CV event. Time-to-CV event was associated with prior stroke (HR 2.01, 95% CI 1.03–3.90), prior MI (HR 1.70, 95% CI 1.06–2.71), hyperlipidemia (HR 1.57, 95% CI 1.01–2.43), and increased modified Charlson-Deyo index (HR 1.23, 95% CI 1.13–1.34). MTX use (HR 0.66, 95% CI 0.44–0.99) and increasing education (HR 0.87, 95% CI 0.80–0.95) were associated with a lower risk for CV events. Conclusion. Although MTHFR polymorphisms were previously associated with CV events in non-RA populations, we found only a trend toward decreased association with CV events in RA. Traditional risk factors conferred substantial CV risk, while MTX use and increasing years of education were protective.

Evaluation of a national telemedicine initiative in the Veterans Health Administration: Factors associated with successful implementation.

Background The Consolidated Framework for Implementation Research was used to evaluate implementation facilitators and barriers of Specialty Care Access Network-Extension for Community Healthcare Outcomes (SCAN-ECHO) within the Veterans Health Administration. SCAN-ECHO is a video teleconferencing-based programme where specialist teams train and mentor remotely-located primary care providers in providing routine speciality care for common chronic illnesses. The goal of SCAN-ECHO was to improve access to speciality care for Veterans. The aim of this study was to provide guidance and support for the implementation and spread of SCAN-ECHO. Methods Semi-structured telephone interviews with 55 key informants (primary care providers, specialists and support staff) were conducted post-implementation with nine sites and analysed using Consolidated Framework for Implementation Research constructs. Data were analysed to distinguish sites based on level of implementation measured by the numbers of SCAN-ECHO sessions. Surveys with all SCAN-ECHO sites further explored implementation information. Results Analysis of the interviews revealed three of 14 Consolidated Framework for Implementation Research constructs that distinguished between low and high implementation sites: design quality and packaging; compatibility; and reflecting and evaluating. The survey data generally supported these findings, while also revealing a fourth distinguishing construct – leadership engagement. All sites expressed positive attitudes toward SCAN-ECHO, despite struggling with the complexity of programme implementation. Conclusions Recommendations based on the findings include: (a) expend more effort in developing and distributing educational materials; (b) restructure the delivery process to improve programme compatibility; (c) establish an audit and feedback mechanism for monitoring and improving the programme; (d) engage in more upfront planning to reduce complexity; and (e) obtain local leadership support for providing primary care providers with dedicated time for participation.

Two Complementary Personal Medication Management Applications Developed on a Common Platform: Case Report

Background Adverse drug events are a major safety issue in ambulatory care. Improving medication self-management could reduce these adverse events. Researchers have developed medication applications for tethered personal health records (PHRs), but little has been reported about medication applications for interoperable PHRs. Objective Our objective was to develop two complementary personal health applications on a common PHR platform: one to assist children with complex health needs (MyMediHealth), and one to assist older adults in care transitions (Colorado Care Tablet). Methods The applications were developed using a user-centered design approach. The two applications shared a common PHR platform based on a service-oriented architecture. MyMediHealth employed Web and mobile phone user interfaces. Colorado Care Tablet employed a Web interface customized for a tablet PC. Results We created complementary medication management applications tailored to the needs of distinctly different user groups using common components. Challenges were addressed in multiple areas, including how to encode medication identities, how to incorporate knowledge bases for medication images and consumer health information, how to include supplementary dosing information, how to simplify user interfaces for older adults, and how to support mobile devices for children. Conclusions These prototypes demonstrate the utility of abstracting PHR data and services (the PHR platform) from applications that can be tailored to meet the needs of diverse patients. Based on the challenges we faced, we provide recommendations on the structure of publicly available knowledge resources and the use of mobile messaging systems for PHR applications.

Barriers and facilitators for preventing Adverse Drug Reactions of Long Latency: A qualitative study

OBJECTIVE To understand the practices medical care providers and health care staff utilize in managing and preventing Adverse Drug Reactions of Long Latency (ADRLLs) among their patients on medications such as glucocorticoids. DESIGN Qualitative study of key informant interviews. SETTING Denver Department of Veterans Affairs (VA) Medical Center. PARTICIPANTS Fourteen physician providers and health care staff (nurses and pharmacists) in primary care and rheumatology. METHODS A trained interviewer conducted semi-structured interviews in which providers and health care staff were asked about their processes for tracking and averting ADRLLs. PARTICIPANTS were asked about barriers and facilitators to monitoring ADRLLs and solicited for suggestions to improve existing processes. Interviews were analyzed using ATLAS.ti software. RESULTS Providers overwhelmingly commented on barriers, rather than facilitators. Six core themes emerged regarding ADRLL management barriers: patient noncompliance, provider workload, complications coordinating care, provider unfamiliarity with ADRLLs, lack of a standardized monitoring system, and communication failures. Ideas to improve the monitoring of ADRLLs fell into two domains: improving automated computer generated reminders or assigning a specific person to monitor potential ADRLLs. CONCLUSIONS Interviewees strongly endorsed a more systematic approach to ADRLL management, either through less intrusive computer-generated system reminders or through a dedicated staff person, such as a pharmacist, who could more closely monitor potential ADRLLs. There was disagreement among interviewees about who is responsible for monitoring ADRLLs (specialists versus primary care providers, VA versus non-VA providers, residents versus attending physicians).