Finding Meaning in Medication Reconciliation Using Electronic Health Records: Qualitative Analysis in Safety Net Primary and Specialty Care

Abstract

Background: Safety net health systems face barriers to effective ambulatory medication reconciliation for vulnerable populations. Although some electronic health record (EHR) systems offer safety advantages, EHR use may affect the quality of patient-provider communication.

Objective: This mixed-methods observational study aimed to develop a conceptual framework of how clinicians balance the demands and risks of EHR and communication tasks during medication reconciliation discussions in a safety net system.

Methods: This study occurred 3 to 16 (median 9) months after new EHR implementation in five academic public hospital clinics. We video recorded visits between English-/Spanish-speaking patients and their primary/specialty care clinicians. We analyzed the proportion of medications addressed and coded time spent on nonverbal tasks during medication reconciliation as "multitasking EHR use," "silent EHR use," "non-EHR multitasking," and "focused patient-clinician talk." Finally, we analyzed communication patterns to develop a conceptual framework.

Results: We examined 35 visits (17%, 6/35 Spanish) between 25 patients (mean age 57, SD 11 years; 44%, 11/25 women; 48%, 12/25 Hispanic; and 20%, 5/25 with limited health literacy) and 25 clinicians (48%, 12/25 primary care). Patients had listed a median of 7 (IQR 5-12) relevant medications, and clinicians addressed a median of 3 (interquartile range [IQR] 1-5) medications. The median duration of medication reconciliation was 2.1 (IQR 1.0-4.2) minutes, comprising a median of 10% (IQR 3%-17%) of visit time. Multitasking EHR use occurred in 47% (IQR 26%-70%) of the medication reconciliation time. Silent EHR use and non-EHR multitasking occurred a smaller proportion of medication reconciliation time, with a median of 0% for both. Focused clinician-patient talk occurred a median of 24% (IQR 0-39%) of medication reconciliation time. Five communication patterns with EHR medication reconciliation were observed: (1) typical EHR multitasking for medication reconciliation, (2) dynamic EHR use to negotiate medication discrepancies, (3) focused patient-clinician talk for medication counseling and addressing patient concerns, (4) responding to patient concerns while maintaining EHR use, and (5) using EHRs to engage patients during medication reconciliation. We developed a conceptual diagram representing the dilemma of the multitasking clinician during medication reconciliation.

Conclusions: Safety net visits involve multitasking EHR use during almost half of medication reconciliation time. The multitasking clinician balances the cognitive and emotional demands posed by incoming information from multiple sources, attempts to synthesize and act on this information through EHR and communication tasks, and adopts strategies of silent EHR use and focused patient-clinician talk that may help mitigate the risks of multitasking. Future studies should explore diverse patient perspectives about clinician EHR multitasking, clinical outcomes related to EHR multitasking, and human factors and systems engineering interventions to improve the safety of EHR use during the complex process of medication reconciliation.

Keywords: communication; electronic health records; medication reconciliation; patient safety; physician-patient relations.

Figure 1

Multitasking, silent electronic health record (EHR) use, and number of medications explicitly addressed during safety net medication reconciliation (N=35). *Primary care encounters are labeled with a “P” and specialty care encounters with an “S.” The number following each line indicates the number of “addressed” medications out of the total number of “relevant” medications. Medications were categorized as “addressed” if the patient or clinician specifically discussed its current use. For primary care encounters, all medications listed in the patient’s note or discussed during the visit encounter were categorized as “relevant.” For specialty care encounters, medications related to the clinician’s specialty or with drug or disease interactions were categorized as “relevant”; the total number of all medications is listed in parentheses for these specialty encounters. † means clinicians clicked on a box labeled “verified medications” to indicate that medication reconciliation was performed.

Figure 2

Conceptual diagram: multitasking clinicians balancing the demands and risks of electronic health records (EHRs) and communication tasks during medication reconciliation.