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Original Investigation
July 9, 2018

Effect of Electronic Health Record–Based Medication Support and Nurse-Led Medication Therapy Management on Hypertension and Medication Self-managementA Randomized Clinical Trial

Author Affiliations
  • 1Division of General Internal Medicine and Geriatrics, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
  • 2Center for Primary Care Innovation, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
  • 3Division of Cardiology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
  • 4Access Community Health Network and the Access Center for Discovery and Learning, Chicago, Illinois
  • 5Carlson School of Management, University of Minnesota, Minneapolis
  • 6Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
  • 7Information Services, Northwestern Memorial Healthcare, Chicago, Illinois
  • 8Center for Excellence in Primary Care, Department of Family Medicine and Community Health, Medical School, University of Minnesota, Minneapolis
  • 9Department of Ophthalmology and Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
JAMA Intern Med. Published online July 9, 2018. doi:10.1001/jamainternmed.2018.2372
Key Points

Question  Do electronic health record–delivered medication management tools with or without nurse-led medication education improve self-management and lower blood pressure at community health centers?

Findings  In this cluster randomized clinical trial of 794 patients with hypertension, electronic health record tools designed to support medication self-management improved medication reconciliation but may have worsened blood pressure. Electronic health record tools combined with nurse-led medication education were associated with lower blood pressure compared with electronic health record tools alone but had no effect on medication adherence or drug indication knowledge.

Meaning  This study highlights the importance of testing system-level changes for unintended effects and suggests that improving some aspects of medication self-management alone is not sufficient to improve hypertension control.

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.

Trial Registration  ClinicalTrials.gov identifier: NCT01578577

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