Electronic Health Record-Based Strategy to Promote Medication Adherence Among Patients With Diabetes: Longitudinal Observational Study.

BACKGROUND: Poor medication adherence is common; however, few mechanisms exist in clinical practice to monitor how patients take medications in outpatient settings. OBJECTIVE: This study aimed to pilot test the Electronic Medication Complete Communication (EMC2) strategy, a low-cost, sustainable approach that uses functionalities within the electronic health record to promote outpatient medication adherence and safety. METHODS: The EMC2 strategy was implemented in 2 academic practices for 14 higher-risk diabetes medications. The strategy included: (1) clinical decision support alerts to prompt provider counseling on medication risks, (2) low-literacy medication summaries for patients, (3) a portal-based questionnaire to monitor outpatient medication use, and (4) clinical outreach for identified concerns. We recruited adult patients with diabetes who were prescribed a higher-risk diabetes medication. Participants completed baseline and 2-week interviews to assess receipt of, and satisfaction with, intervention components. RESULTS: A total of 100 patients were enrolled; 90 completed the 2-week interview. Patients were racially diverse, 30.0% (30/100) had a high school education or less, and 40.0% (40/100) had limited literacy skills. About a quarter (28/100) did not have a portal account; socioeconomic disparities were noted in account ownership by income and education. Among patients with a portal account, 58% (42/72) completed the questionnaire; 21 of the 42 patients reported concerns warranting clinical follow-up. Of these, 17 were contacted by the clinic or had their issue resolved within 24 hours. Most patients (33/38, 89%) who completed the portal questionnaire and follow-up interview reported high levels of satisfaction (score of 8 or greater on a scale of 1-10). CONCLUSIONS: Findings suggest that the EMC2 strategy can be reliably implemented and delivered to patients, with high levels of satisfaction. Disparities in portal use may restrict intervention reach. Although the EMC2 strategy can be implemented with minimal impact on clinic workflow, future trials are needed to evaluate its effectiveness to promote adherence and safety.

Medical diaspora: an underused entity in low- and middle-income countries' health system development.

BACKGROUND: At present, over 215 million people live outside their countries of birth, many of which are referred to as diaspora-those that live in host countries but maintain strong sentimental and material links with their countries of origin, their homelands. The critical shortage of Human Resources for Health (HRH) in many developing countries remains a barrier to attaining their health system goals. Usage of medical diaspora can be one way to meet this need. A growing number of policy-makers have come to acknowledge that medical diaspora can play a vital role in the development of their homeland's health workforce capacity. To date, no inventory of low- and middle-income countries (LMIC) medical diaspora organizations has been done. This paper intends to develop an inventory that is as complete as possible, of the names of the LMIC medical diaspora organizations in the United States of America, the United Kingdom, Canada, and Australia and addresses their interests and roles in building the health system of their country of origin. METHODS: The researchers utilized six steps for their research methodology: (1) development of rationale for choosing the four destination countries (the United States of America, the United Kingdom, Canada, and Australia); (2) identification of low- and middle-income countries (LMIC); (3) web search for the name of LMIC medical diaspora organization in the United States of America, the United Kingdom, Canada, and Australia through the search engines of PubMed, Scopus, Google, Google Scholar, and LexisNexis; (4) development of inclusion and exclusion criteria and creation of a medical diaspora organizations' inventory list (Table 1) and corresponding maps (Figures 1, 2, and 3). Using decision criteria, reviewers narrowed the number to a final 89 organizations; (5) synthesis of information to collect the general as well as the unique roles the medical diaspora organizations play in building health systems; and (6) developing inventory of respective LMIC governments' diaspora offices (Table 2) to identify units/departments that facilitate diaspora's work. RESULT: In total, the authors found 89 medical diaspora organizations in 4 main countries: in the United States of America 60, in the United Kingdom 24, in Australia 3, and in Canada 2. These medical diaspora organizations tend to have three focuses: providing healthcare services, training, and when needed humanitarian aid to their home country; creating a social or professional network of migrant physicians (i.e., simply to bring together people with an ethnic and professional commonality) and; supplying improved and culturally sensitive healthcare to the migrant population within the host country. Sixty-eight LMIC countries have established a diaspora office within their government office. It is also equally important to note that many policy-makers may lack knowledge of models for medical diaspora engagement or of valuable lessons learned by other governments about working with diaspora. CONCLUSIONS: The medical diaspora remains an underutilized resource in both health systems policy formulation and program implementation.

Development and rationale for a multifactorial, randomized controlled trial to test strategies to promote adherence to complex drug regimens among older adults.

BACKGROUND: Patients with chronic conditions are often responsible for self-managing complex, multi-drug regimens with minimal professional clinical support. While numerous interventions to promote and support medication adherence have been tested, most have had limited success or have been too resource-intensive for real-world implementation. OBJECTIVE: To compare the effectiveness of multiple low-cost, technology-enabled strategies, alone and in combination, for promoting medication regimen adherence among older adults. METHODS: Older, English or Spanish-speaking patients on complex drug regimens (N=1505) will be recruited from a community health system in Chicago, IL. Enrolled patients will be randomized to one of four study arms, receiving either: 1) enhanced usual care alone; 2) daily medication reminders via SMS text messages; 3) medication monitoring via a patient portal-based assessment; or 4) both SMS text message reminders and portal-based medication monitoring. The primary outcome of the study is medication adherence, which will be assessed via multiple measures at baseline, 2months, and 6months. The effect of intervention strategies on clinical markers (hemoglobin A1c, blood pressure, cholesterol level), as well as intervention fidelity and the barriers and costs of implementation will also be evaluated. CONCLUSIONS: This randomized controlled trial will evaluate the impact of various low-cost intervention strategies on adherence to complex medication regimens and will explore barriers to implementation. If the studied intervention strategies are shown to be effective, then these approaches could be effectively deployed across a diverse range of clinical settings and patient populations. CLINICAL TRIAL REGISTRATION: This trial is registered on clinicaltrials.govNCT02820753.

An Electronic Health Record-Based Strategy to Systematically Assess Medication Use Among Primary Care Patients With Multidrug Regimens: Feasibility Study.

BACKGROUND: Medication nonadherence and misuse are public health and patient safety concerns. With the increased adoption of electronic health records (EHRs), greater opportunities exist to communicate directly with, and collect data from, patients through secure portals linked to EHRs. OBJECTIVE: The study objectives were to develop and pilot test a method of monitoring patient medication use in outpatient settings and determine the feasibility and acceptability of this approach. METHODS: Adult primary care patients on multidrug regimens were recruited from an academic internal medicine clinic by a trained research assistant. After completing a baseline, in-person interview, patients were sent a link to a questionnaire about medication use via the patient portal. One week later, the RA contacted patients to complete a follow-up telephone interview assessing patient satisfaction and experience with the questionnaire. Patient EHRs were also reviewed to determine the questionnaire completion rate. RESULTS: Of 100 patients enrolled, 89 completed the follow-up interview and 82 completed the portal questionnaire. The mean age of the sample was 61.8 (range 31-88) years. Approximately half (54/100, 54%) of the sample was male, two-thirds were white (67/100, 67%) and 26% (26/100) African-American. A total of 44% reported an annual household income of <$50,000 per year, and 17% (17/100) reported a high school or less level of education. No significant differences were found in questionnaire completion rates by sociodemographic characteristics or prior portal use. Most (68/73, 93%) found the questionnaire easy to access, easy to complete (72/73, 99%), and valuable (73/89, 82%). Time constraints and log-in difficulties were the main reasons for noncompletion. CONCLUSIONS: The portal questionnaire was well received by a socioeconomically diverse group of patients with high completion rates achieved. Routine use of a portal-based questionnaire could provide a valuable signal to providers and care teams about patient medication use and identify patients needing additional support.

Building communities of practice: MEPI creates a commons.

The Medical Education Partnership Initiative (MEPI) supports medical education capacity development, retention, and research in Sub-Saharan African institutions. Today, MEPI comprises more than 40 medical schools in Africa and 20 in the United States. Since 2011, the MEPI Coordinating Center, working with the MEPI schools and the U.S. government, has laid the groundwork and served as a catalyst for the creation and development of MEPI "communities of practice" (CoPs). These CoPs encompass seven components, some of which are virtual while others are tangible. They include technical working groups, principal investigator site visit exchanges, an annual symposium, a MEPI journal supplement, the MEPI Web site, newsletters, and webinars. Despite certain challenges and the question of sustainability, the presence within the MEPI network of an organization focused on promoting group consciousness and facilitating collaborative projects is an asset that is likely to continue to pay dividends for the foreseeable future.