Health informatics interventions to minimize out-of-pocket medication costs for patients: what providers want.

Objective: To explore diverse provider perspectives on: strategies for addressing patient medication cost barriers; patient medication cost information gaps; current medication cost-related informatics tools; and design features for future tool development. Materials and Methods: We conducted 38 semistructured interviews with providers (physicians, nurses, pharmacists, social workers, and administrators) in a Midwestern health system in the United States. We used 3 rounds of qualitative coding to identify themes. Results: Providers lacked access to information about: patients' ability to pay for medications; true costs of full medication regimens; and cost impacts of patient insurance changes. Some providers said that while existing cost-related tools were helpful, they contained unclear insurance information and several questioned the information's quality. Cost-related information was not available to everyone who needed it and was not always available when needed. Fragmentation of information across sources made cost-alleviation information difficult to access. Providers desired future tools to compare medication costs more directly; provide quick references on costs to facilitate clinical conversations; streamline medication resource referrals; and provide centrally accessible visual summaries of patient affordability challenges. Discussion: These findings can inform the next generation of informatics tools for minimizing patients' out-of-pocket costs. Future tools should support the work of a wider range of providers and situations and use cases than current tools do. Such tools would have the potential to improve prescribing decisions and better link patients to resources. Conclusion: Results identified opportunities to fill multidisciplinary providers' information gaps and ways in which new tools could better support medication affordability for patients.

"It's a mess sometimes": patient perspectives on provider responses to healthcare costs, and how informatics interventions can help support cost-sensitive care decisions.

OBJECTIVE: We investigated patient experiences with medication- and test-related cost conversations with healthcare providers to identify their preferences for future informatics tools to facilitate cost-sensitive care decisions. MATERIALS AND METHODS: We conducted 18 semistructured interviews with diverse patients (ages 24-81) in a Midwestern health system in the United States. We identified themes through 2 rounds of qualitative coding. RESULTS: Patients believed their providers could help reduce medication-related costs but did not see how providers could influence test-related costs. Patients viewed cost conversations about medications as beneficial when providers could adjust medical recommendations or provide resources. However, cost conversations did not always occur when patients felt they were needed. Consequently, patients faced a "cascade of work" to address affordability challenges. To prevent this, collaborative informatics tools could facilitate cost conversations and shared decision-making by providing information about a patient's financial constraints, enabling comparisons of medication/testing options, and addressing transportation logistics to facilitate patient follow-through. DISCUSSION: Like providers, patients want informatics tools that address patient out-of-pocket costs. They want to discuss healthcare costs to reduce the frequency of unaffordable costs and obtain proactive assistance. Informatics interventions could minimize the cascade of patient work through shared decision-making and preventative actions. Such tools might integrate information about efficacy, costs, and side effects to support decisions, present patient decision aids, facilitate coordination among healthcare units, and eventually improve patient outcomes. CONCLUSION: To prevent a burdensome cascade of work for patients, informatics tools could be designed to support cost conversations and decisions between patients and providers.

Medication adherence for atrial fibrillation patients: triangulating measures from a smart pill bottle, e-prescribing software, and patient communication through the electronic health record.

OBJECTIVE: Our primary objectives were to examine adherence rates across two technologies (e-prescribing software and smart pill bottle) with cross-validation from alert-triggered messaging within the patient electronic health record (EHR) portal and to explore the benefits and challenges faced by atrial fibrillation (AF) patients in using a smart pill bottle. MATERIALS AND METHODS: We triangulated the rate of oral anticoagulant medication adherence among 160 AF patients over 6 months using an EHR in combination with data from the AdhereTech© Wireless Smart Pill Bottle and Surescripts©. In addition, we collected qualitative feedback on patients' Smart Pill Bottle usage through structured interviews with 153 participants. RESULTS: Patients maintained an average adherence rate of 90.0% according to the smart pill bottle; however, when dose misses were calibrated based on patient or provider feedback, the adjusted adherence was 93.6%. Surescripts adherence rates for refills were 92.2%. Participants generally found the bottle easy to operate but suggested that its size and functionality did not fit seamlessly into their existing routine, as many used weekly pill organizers to manage multiple medications. DISCUSSION: Though each method of tracking adherence has positive and negative attributes, combining them and seeking patient feedback may help capture a more accurate adherence rate than any single technological intervention. Technologies may have different design considerations for research and consumer use. CONCLUSION: Overall, these technologies provide useful but imperfect adherence data for research purposes, and smart pill bottles could be improved with patient-centered design. LAY SUMMARY: Medication adherence is very important for those with chronic health issues. For those with heart disease, medication adherence not only offers opportunities for improving quality of life, but it also can be life-saving. Nonetheless, many patients with heart disease, including those with atrial fibrillation (the target group for this study) do not take their medications regularly. As technologies advance, there is unprecedented opportunity to track patients' medication adherence through various methods, which might provide motivation and information to patients as they make daily choices about medication use. In this study, we cross-referenced the results of two of these measures over 6 months-a smart pill bottle, which we used to track pill bottle openings, and e-prescribing software, which we used to track medication refills. We also supplemented these measures with nurse-patient communication via the EHR messaging portal to record exceptions (eg, travel and medication changes) and interviewed patients about their medication use during the 6-month trial. Overall, the tracking technologies worked relatively well to track patient (n = 160) medication behavior; however, they did not capture exceptions. Hence, triangulating data from different sources, with a patient feedback loop, appears critical for gathering accurate data on medication adherence.