In the U.S., 4.5 million ambulatory care visits occur annually due to adverse drug reactions (ADRs) of prescription medications.1 Many ADRs are severe, and they result in more than 100,000 death per year.2 A significant number of these ADRs are preventable and are a result of inappropriate prescribing.3 It is well-documented that inappropriate prescribing is exacerbated by the number of patients who see multiple prescribers and use many different prescription medications.4 This situation results in many versions of a patient’s medication list and in discrepancies across data sources.5
Medication list discrepancies have been researched in the context of care transitions between the hospital and home.6,7 However, less attention has been given to community-dwelling adults who use multiple outpatient prescribers, a practice common among older adults with chronic conditions who see a primary care provider and several specialists.4 Also, veterans are a growing patient population who use providers from multiple health care systems.8 Up to 70% of veterans enrolled in VA health care use both VA and non-VA providers. These patients are referred to as dual users.9,10
There has been an increasing push for patients to be more actively engaged in their own health care, including maintenance of their medication list and other personal health information.11-13 Providers have realized that patients have important experiences and preferences to share about how they use medications at home.14,15 Research suggests that patient interest and ability to use patient portals is variable and dependent on age, technical abilities, health literacy, and endorsement by their providers.16 Greater patient engagement in the medication management process is potentially advantageous, especially because providers from different health care systems often lack the capability to share medication list information.12,17
My HealtheVet, the VA’s patient portal, offers veterans several features. For example, users can securely message providers, refill prescriptions, check appointments, self-enter information, and download their VA health record (including medication history) using the Blue Button (BB) feature. The BB is managed by the HHS to provide consistency across electronic health record platforms.18,19
This BB medication list gives VA patients the tool they need to inform their providers about the medications they take, particularly dual users. VA patients that use multiple prescribers are subject to medication list discrepancies because of the fragmentation of information.4,20
The objectives of this study were to (1) describe discrepancies between VA medication lists and non-VA provider medication lists for a group of veteran dual users; (2) identify therapeutic duplications in these lists; and (3) contextualize discrepancies by interviewing non-VA providers about their medication reconciliation processes and management of dual use patients.
This analysis is based on data collected as part of a pilot randomized controlled trial by Turvey and colleagues.21 Veterans with a diagnosis of ≥ 1 chronic health condition (eg, diabetes, hypertension) were invited by letter to participate in a study about using online management of their health information. Interested patients were screened to meet additional inclusion criteria, such as taking ≥ 5 medications, receiving care from a non-VA provider, an appointment with a non-VA provider within the study time frame, and access to a computer, online access, and printer.
Eligible veterans were randomized to receive either (1) BB training (intervention group) instructing patients to download the Continuity of Care Document and bring it to their non-VA provider visit; or (2) a training evaluating medical information online (control group). Training information was mailed, including written materials and phone support, to both groups. The intervention group could also access an online training link.
One of the objectives was to test whether downloading and bringing the health information to a non-VA appointment decreased medication list discrepancies. The sample was small, and differences in discrepancy rates between groups were not significant. Therefore, groups were combined for the present analysis. Visits occurred between December 2013 and December 2014. Greater detail about study design and primary results are available in the study by Turvey and colleagues.21
Study procedures were approved by the University of Iowa Institutional Review Board and the Iowa City VA Health Care System Research and Development Committee. All participants provided consent.
A 4-phase process was used to address medication discrepancies.22,23 The first phase defined medication discrepancy categories. The mutually exclusive categories were dose, frequency, and missing discrepancies. In cases where a medication was both dose and frequency discrepant, only dose discrepancy was applied. For missing medications, entities on only the VA list were marked as “non-VA missing” and medications appearing on only the non-VA list would be denoted as “VA missing.” Medications with no discrepancy were marked as such.