Effect of electronic health record–based medication support and nurse-led medication therapy management on hypertension and medication self-management: A randomized clinical trial

Stephen D Persell, Kunal N. Karmali, Danielle Lazar, Elisha M. Friesema, Ji Young Lee, Alfred W Rademaker, Darren Kaiser, Milton Eder, Dustin Douglas French, Tiffany Brown, Michael Wolf

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Abstract

IMPORTANCE Complex medication regimens pose self-management challenges, particularly among populations with low levels of health literacy. OBJECTIVE To test medication management tools delivered through a commercial electronic health record (EHR) with and without a nurse-led education intervention. DESIGN, SETTING, AND PARTICIPANTS This 3-group cluster randomized clinical trial was performed in community health centers in Chicago, Illinois. Participants included 794 patients with hypertension who self-reported using 3 or more medications concurrently (for any purpose). Data were collected from April 30, 2012, through February 29, 2016, and analyzed by intention to treat. INTERVENTIONS Clinics were randomly assigned to to groups: electronic health record–based medication management tools (medication review sheets at visit check-in, lay medication information sheets printed after visits; EHR-alone group), EHR-based tools plus nurse-led medication management support (EHR plus education group), or usual care. MAIN OUTCOMES AND MEASURES Outcomes at 12 months included systolic blood pressure (primary outcome), medication reconciliation, knowledge of drug indications, understanding of medication instructions and dosing, and self-reported medication adherence. Medication outcomes were assessed for all hypertension prescriptions, all prescriptions to treat chronic disease, and all medications. RESULTS Among the 794 participants (68.6% women; mean [SD] age, 52.7 [9.6] years), systolic blood pressure at 12 months was greater in the EHR-alone group compared with the usual care group by 3.6 mm Hg (95% CI, 0.3 to 6.9 mm Hg). Systolic blood pressure in the EHR plus education group was not significantly lower compared with the usual care group (difference, −2.0 mm Hg; 95% CI, −5.2 to 1.3 mm Hg) but was lower compared with the EHR-alone group (−5.6 mm Hg; 95% CI, −8.8 to −2.4 mm Hg). At 12 months, hypertension medication reconciliation was improved in the EHR-alone group (adjusted odds ratio [OR], 1.8; 95% CI, 1.1 to 2.9) and the EHR plus education group (adjusted odds ratio [OR], 2.0; 95% CI, 1.3 to 3.3) compared with usual care. Understanding of medication instructions and dosing was greater in the EHR plus education group than the usual care group for hypertension medications (OR, 2.3; 95% CI, 1.1 to 4.8) and all medications combined (OR, 1.7; 95% CI, 1.0 to 2.8). Compared with usual care, the EHR tools alone and EHR plus education interventions did not improve hypertension medication adherence (OR, 0.9; 95% CI, 0.6-1.4 for both) or knowledge of chronic drug indications (OR for EHR tools alone, 1.0 [95% CI, 0.6 to 1.5] and OR for EHR plus education, 1.1 [95% CI, 0.7-1.7]). CONCLUSIONS AND RELEVANCE The study found that EHR tools in isolation improved medication reconciliation but worsened blood pressure. Combining these tools with nurse-led support suggested improved understanding of medication instructions and dosing but did not lower blood pressure compared with usual care.

LanguageEnglish (US)
Pages1069-1077
Number of pages9
JournalJAMA Internal Medicine
Volume178
Issue number8
DOIs
StatePublished - Aug 1 2018

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Medication Therapy Management
Electronic Health Records
Self Care
Randomized Controlled Trials
Nurses
Hypertension
Blood Pressure
Odds Ratio
Medication Reconciliation
Education
Medication Adherence
Prescriptions
Health Literacy
Community Health Centers

ASJC Scopus subject areas

  • Internal Medicine

Cite this

@article{3870291cd54c48ffb7e8f16ad45246ba,
title = "Effect of electronic health record–based medication support and nurse-led medication therapy management on hypertension and medication self-management: A randomized clinical trial",
abstract = "IMPORTANCE Complex medication regimens pose self-management challenges, particularly among populations with low levels of health literacy. OBJECTIVE To test medication management tools delivered through a commercial electronic health record (EHR) with and without a nurse-led education intervention. DESIGN, SETTING, AND PARTICIPANTS This 3-group cluster randomized clinical trial was performed in community health centers in Chicago, Illinois. Participants included 794 patients with hypertension who self-reported using 3 or more medications concurrently (for any purpose). Data were collected from April 30, 2012, through February 29, 2016, and analyzed by intention to treat. INTERVENTIONS Clinics were randomly assigned to to groups: electronic health record–based medication management tools (medication review sheets at visit check-in, lay medication information sheets printed after visits; EHR-alone group), EHR-based tools plus nurse-led medication management support (EHR plus education group), or usual care. MAIN OUTCOMES AND MEASURES Outcomes at 12 months included systolic blood pressure (primary outcome), medication reconciliation, knowledge of drug indications, understanding of medication instructions and dosing, and self-reported medication adherence. Medication outcomes were assessed for all hypertension prescriptions, all prescriptions to treat chronic disease, and all medications. RESULTS Among the 794 participants (68.6{\%} women; mean [SD] age, 52.7 [9.6] years), systolic blood pressure at 12 months was greater in the EHR-alone group compared with the usual care group by 3.6 mm Hg (95{\%} CI, 0.3 to 6.9 mm Hg). Systolic blood pressure in the EHR plus education group was not significantly lower compared with the usual care group (difference, −2.0 mm Hg; 95{\%} CI, −5.2 to 1.3 mm Hg) but was lower compared with the EHR-alone group (−5.6 mm Hg; 95{\%} CI, −8.8 to −2.4 mm Hg). At 12 months, hypertension medication reconciliation was improved in the EHR-alone group (adjusted odds ratio [OR], 1.8; 95{\%} CI, 1.1 to 2.9) and the EHR plus education group (adjusted odds ratio [OR], 2.0; 95{\%} CI, 1.3 to 3.3) compared with usual care. Understanding of medication instructions and dosing was greater in the EHR plus education group than the usual care group for hypertension medications (OR, 2.3; 95{\%} CI, 1.1 to 4.8) and all medications combined (OR, 1.7; 95{\%} CI, 1.0 to 2.8). Compared with usual care, the EHR tools alone and EHR plus education interventions did not improve hypertension medication adherence (OR, 0.9; 95{\%} CI, 0.6-1.4 for both) or knowledge of chronic drug indications (OR for EHR tools alone, 1.0 [95{\%} CI, 0.6 to 1.5] and OR for EHR plus education, 1.1 [95{\%} CI, 0.7-1.7]). CONCLUSIONS AND RELEVANCE The study found that EHR tools in isolation improved medication reconciliation but worsened blood pressure. Combining these tools with nurse-led support suggested improved understanding of medication instructions and dosing but did not lower blood pressure compared with usual care.",
author = "Persell, {Stephen D} and Karmali, {Kunal N.} and Danielle Lazar and Friesema, {Elisha M.} and Lee, {Ji Young} and Rademaker, {Alfred W} and Darren Kaiser and Milton Eder and French, {Dustin Douglas} and Tiffany Brown and Michael Wolf",
year = "2018",
month = "8",
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doi = "10.1001/jamainternmed.2018.2372",
language = "English (US)",
volume = "178",
pages = "1069--1077",
journal = "JAMA Internal Medicine",
issn = "2168-6106",
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Effect of electronic health record–based medication support and nurse-led medication therapy management on hypertension and medication self-management : A randomized clinical trial. / Persell, Stephen D; Karmali, Kunal N.; Lazar, Danielle; Friesema, Elisha M.; Lee, Ji Young; Rademaker, Alfred W; Kaiser, Darren; Eder, Milton; French, Dustin Douglas; Brown, Tiffany; Wolf, Michael.

In: JAMA Internal Medicine, Vol. 178, No. 8, 01.08.2018, p. 1069-1077.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Effect of electronic health record–based medication support and nurse-led medication therapy management on hypertension and medication self-management

T2 - JAMA Internal Medicine

AU - Persell, Stephen D

AU - Karmali, Kunal N.

AU - Lazar, Danielle

AU - Friesema, Elisha M.

AU - Lee, Ji Young

AU - Rademaker, Alfred W

AU - Kaiser, Darren

AU - Eder, Milton

AU - French, Dustin Douglas

AU - Brown, Tiffany

AU - Wolf, Michael

PY - 2018/8/1

Y1 - 2018/8/1

N2 - IMPORTANCE Complex medication regimens pose self-management challenges, particularly among populations with low levels of health literacy. OBJECTIVE To test medication management tools delivered through a commercial electronic health record (EHR) with and without a nurse-led education intervention. DESIGN, SETTING, AND PARTICIPANTS This 3-group cluster randomized clinical trial was performed in community health centers in Chicago, Illinois. Participants included 794 patients with hypertension who self-reported using 3 or more medications concurrently (for any purpose). Data were collected from April 30, 2012, through February 29, 2016, and analyzed by intention to treat. INTERVENTIONS Clinics were randomly assigned to to groups: electronic health record–based medication management tools (medication review sheets at visit check-in, lay medication information sheets printed after visits; EHR-alone group), EHR-based tools plus nurse-led medication management support (EHR plus education group), or usual care. MAIN OUTCOMES AND MEASURES Outcomes at 12 months included systolic blood pressure (primary outcome), medication reconciliation, knowledge of drug indications, understanding of medication instructions and dosing, and self-reported medication adherence. Medication outcomes were assessed for all hypertension prescriptions, all prescriptions to treat chronic disease, and all medications. RESULTS Among the 794 participants (68.6% women; mean [SD] age, 52.7 [9.6] years), systolic blood pressure at 12 months was greater in the EHR-alone group compared with the usual care group by 3.6 mm Hg (95% CI, 0.3 to 6.9 mm Hg). Systolic blood pressure in the EHR plus education group was not significantly lower compared with the usual care group (difference, −2.0 mm Hg; 95% CI, −5.2 to 1.3 mm Hg) but was lower compared with the EHR-alone group (−5.6 mm Hg; 95% CI, −8.8 to −2.4 mm Hg). At 12 months, hypertension medication reconciliation was improved in the EHR-alone group (adjusted odds ratio [OR], 1.8; 95% CI, 1.1 to 2.9) and the EHR plus education group (adjusted odds ratio [OR], 2.0; 95% CI, 1.3 to 3.3) compared with usual care. Understanding of medication instructions and dosing was greater in the EHR plus education group than the usual care group for hypertension medications (OR, 2.3; 95% CI, 1.1 to 4.8) and all medications combined (OR, 1.7; 95% CI, 1.0 to 2.8). Compared with usual care, the EHR tools alone and EHR plus education interventions did not improve hypertension medication adherence (OR, 0.9; 95% CI, 0.6-1.4 for both) or knowledge of chronic drug indications (OR for EHR tools alone, 1.0 [95% CI, 0.6 to 1.5] and OR for EHR plus education, 1.1 [95% CI, 0.7-1.7]). CONCLUSIONS AND RELEVANCE The study found that EHR tools in isolation improved medication reconciliation but worsened blood pressure. Combining these tools with nurse-led support suggested improved understanding of medication instructions and dosing but did not lower blood pressure compared with usual care.

AB - IMPORTANCE Complex medication regimens pose self-management challenges, particularly among populations with low levels of health literacy. OBJECTIVE To test medication management tools delivered through a commercial electronic health record (EHR) with and without a nurse-led education intervention. DESIGN, SETTING, AND PARTICIPANTS This 3-group cluster randomized clinical trial was performed in community health centers in Chicago, Illinois. Participants included 794 patients with hypertension who self-reported using 3 or more medications concurrently (for any purpose). Data were collected from April 30, 2012, through February 29, 2016, and analyzed by intention to treat. INTERVENTIONS Clinics were randomly assigned to to groups: electronic health record–based medication management tools (medication review sheets at visit check-in, lay medication information sheets printed after visits; EHR-alone group), EHR-based tools plus nurse-led medication management support (EHR plus education group), or usual care. MAIN OUTCOMES AND MEASURES Outcomes at 12 months included systolic blood pressure (primary outcome), medication reconciliation, knowledge of drug indications, understanding of medication instructions and dosing, and self-reported medication adherence. Medication outcomes were assessed for all hypertension prescriptions, all prescriptions to treat chronic disease, and all medications. RESULTS Among the 794 participants (68.6% women; mean [SD] age, 52.7 [9.6] years), systolic blood pressure at 12 months was greater in the EHR-alone group compared with the usual care group by 3.6 mm Hg (95% CI, 0.3 to 6.9 mm Hg). Systolic blood pressure in the EHR plus education group was not significantly lower compared with the usual care group (difference, −2.0 mm Hg; 95% CI, −5.2 to 1.3 mm Hg) but was lower compared with the EHR-alone group (−5.6 mm Hg; 95% CI, −8.8 to −2.4 mm Hg). At 12 months, hypertension medication reconciliation was improved in the EHR-alone group (adjusted odds ratio [OR], 1.8; 95% CI, 1.1 to 2.9) and the EHR plus education group (adjusted odds ratio [OR], 2.0; 95% CI, 1.3 to 3.3) compared with usual care. Understanding of medication instructions and dosing was greater in the EHR plus education group than the usual care group for hypertension medications (OR, 2.3; 95% CI, 1.1 to 4.8) and all medications combined (OR, 1.7; 95% CI, 1.0 to 2.8). Compared with usual care, the EHR tools alone and EHR plus education interventions did not improve hypertension medication adherence (OR, 0.9; 95% CI, 0.6-1.4 for both) or knowledge of chronic drug indications (OR for EHR tools alone, 1.0 [95% CI, 0.6 to 1.5] and OR for EHR plus education, 1.1 [95% CI, 0.7-1.7]). CONCLUSIONS AND RELEVANCE The study found that EHR tools in isolation improved medication reconciliation but worsened blood pressure. Combining these tools with nurse-led support suggested improved understanding of medication instructions and dosing but did not lower blood pressure compared with usual care.

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