Electronic Reminders Research Articles

Strategies Associated with Higher Postpartum Glucose Tolerance Screening Rates for Gestational Diabetes Mellitus Patients

Most women with histories of gestational diabetes mellitus do not receive a postpartum screening test for type 2 diabetes, even though they are at increased risk. The objective of this study was to identify factors associated with high rates of postpartum glucose screening. This cross-sectional analysis assessed characteristics associated with postpartum diabetes screening for patients with gestational diabetes mellitus (GDM)-affected pregnancies self-reported by randomly sampled licensed obstetricians/gynecologists (OBs/GYNs) in Ohio in 2010. Responses were received from 306 OBs/GYNs (56.5% response rate), among whom 69.9% reported frequently (always/most of the time) screening women with GDM-affected pregnancies for abnormal glucose tolerance at the postpartum visit. Compared to infrequent screeners, OBs/GYNs who frequently screen for postpartum glucose tolerance were statistically (p<0.05) more likely to have a clinical protocol addressing postpartum testing (67.2% vs. 26.7%), an electronic reminder system for providers (10.8% vs. 2.2%) and provide reminders to patients (16.4% vs. 4.4%). Frequent screeners were more likely to use recommended fasting blood glucose or 2-hour oral glucose tolerance test (61.8% vs. 34.6%, p<0.001) than infrequent screeners. Strategies associated with higher postpartum glucose screening for GDM patients included clinical protocols for postpartum testing, electronic medical records to alert providers of the need for testing, and reminders to patients.

Barriers to patient adherence with adjuvant endocrine therapy.

6605 Background: Adjuvant endocrine therapy for hormone receptor positive breast cancer is essential to decreasing recurrence and improving survival. However, adherence to these drugs has been reported to be suboptimal, the impact of which on breast cancer outcomes is unknown. Multiple non-modifiable risk factors have been associated with nonadherence. Identifying patients’ self-reported reasons for not taking these drugs as prescribed may be crucial to improving adherence. Methods: We obtained data from 49 women prescribed tamoxifen, letrozole, anastrozole, or exemestane for stage I-III invasive breast cancer. Written surveys were provided during the patients’ medical oncology visits. Our study collected demographic data on patient characteristics associated with nonadherence. Patients were asked to report reasons for missing doses including forgetting to take the drug, side effects, cost, and barriers to refill. Patients described their degree of adherence by identifying how often they miss a dose as never, once per month, once per week, or more than once per week. We compared their self-reported adherence to pharmacy refill records. Results: More than half the women (26 of 49) report regularly missing doses of their drug over the last year. Of these, 22 miss once per month, 3 miss once per week, and 1 misses more than once per week. Despite this, pharmacy records verified consistent refills in all 26 less adherent patients over the past year. The most common reason identified for missed doses (21 of 26) was forgetting to take the drug, followed by barriers to refill and side effects. 57% of all patients favored receiving an electronic reminder via text messaging or email. Nonadherence was associated with polypharmacy and lower levels of education, income, and activity. Conclusions: Our study provides insight into patient reported reasons for nonadherence to adjuvant endocrine therapy. Our patients reported forgetting to take their drug as most problematic. Patients’ self-reported adherence was confirmed (96%) by pharmacy records. Most patients are interested in an electronic reminder system via e-mail or text messaging, even if they report complete adherence. This has potential to be a cost effective intervention.

Central Implementation Strategies Outperform Local Ones in Improving HIV Testing in Veterans Healthcare Administration Facilities

Pilot data suggest that a multifaceted approach may increase HIV testing rates, but the scalability of this approach and the level of support needed for successful implementation remain unknown. To evaluate the effectiveness of a scaled-up multi-component intervention in increasing the rate of risk-based and routine HIV diagnostic testing in primary care clinics and the impact of differing levels of program support. Three arm, quasi-experimental implementation research study. Veterans Health Administration (VHA) facilities. Persons receiving primary care between June 2009 and September 2011 INTERVENTION: A multimodal program, including a real-time electronic clinical reminder to facilitate HIV testing, provider feedback reports and provider education, was implemented in Central and Local Arm Sites; sites in the Central Arm also received ongoing programmatic support. Control Arm sites had no intervention Frequency of performing HIV testing during the 6 months before and after implementation of a risk-based clinical reminder (phase I) or routine clinical reminder (phase II). The adjusted rate of risk-based testing increased by 0.4 %, 5.6 % and 10.1 % in the Control, Local and Central Arms, respectively (all comparisons, p < 0.01). During phase II, the adjusted rate of routine testing increased by 1.1 %, 6.3 % and 9.2 % in the Control, Local and Central Arms, respectively (all comparisons, p < 0.01). At study end, 70-80 % of patients had been offered an HIV test. Use of clinical reminders, provider feedback, education and social marketing significantly increased the frequency at which HIV testing is offered and performed in VHA facilities. These findings support a multimodal approach toward achieving the goal of having every American know their HIV status as a matter of routine clinical practice.

Organization of Diabetes Care

Organization of Diabetes Care

Systematic Collection of Patient-Reported Adverse Drug Reactions: A Path to Patient-Centred Pharmacovigilance

1 IntroductionOver the past 15 years, evidence has mounted that patientself-reporting of symptomatic adverse drug reactions isboth feasible and informative. Multiple recent reports havedescribed programmes internationally in which patientself-reports provide data beyond reporting by health pro-fessionals [1–5]. Various models have been used and thereare several essential lessons to be learned from theseexperiences, in addition to work using patient-reported datain related contexts such as clinical trials and routine clin-ical practice.2 It is Essential to Systematically Collect Informationfrom Patients Rather than Rely on SpontaneousReportingMany adverse event reporting systems rely on volun-tary (spontaneous) reports by patients and/or clinicians.Although submitted information can be informative insome cases, the denominator of potential reporters isunknown, and many adverse reactions are missed due tolack of interest, willingness, availability, or awareness ofstakeholders to report. As a result, the absolute number ofreports collected via these systems is generally low andoften does not reflect the experience of patients comparedwith systematic collection [6]. Patients are not engaged aspartners in the data collection enterprise.Systematic elicitation of information from patientsprovides a known denominator and a more comprehensivepicture within a population. This can be achieved in limitedpopulations via registries, or through wide implementationusing existing or envisioned infrastructure to engagepatients. The paper by Leone et al. in this issue of DrugSafety [7] describes successful implementation of a regio-nal programme through the mechanism of local pharma-cies. Information is systematically elicited from patientswho are engaged by their local pharmacists. This approachdoes more than use an existing infrastructure of localpharmacies for distribution of questionnaires–it creates apartnership between practitioners and patients in anendeavour to understand the experience of both the indi-vidual patient and the broader population.This programme mirrors successful engagement approa-ches in other contexts, such as clinical trials where datamanagers form relationships with patients to encouragereporting, or routine practice settings where customizedinvitation letters are sent to patients from their doctor ornurse.3 Backup Data Collection Systems ReduceMissing DataA lesson learned from the collection of patient-reportedinformation in prospective clinical trials and registries isthat the frequency of missing patient reports is highlydependent on how this information is collected. In partic-ular, data can be recovered from those who are initiallyunable or unwilling to self-report, through the use ofbackup data collection methods. These may include elec-tronic reminders via mail, email or telephone, with ahuman call to those who continue not to report. This

A location-based personal task reminder for mobile users

Personal task reminders have been indispensable for modern people, in order to remind them of their tasks at specific circumstances. Traditional paper-based reminders are still useful, but they cannot be organized efficiently. Electronic reminders based on the calendar in cell phones are more efficient and gaining popularity, but such reminders are mostly triggered by time. In many situations, tasks are only meaningful to be performed at a specific location, so it would be useful if reminders for those tasks can be triggered only when the person to be reminded is physically near or located at that location. Therefore, in this research, we develop a location-based personal task reminder for Android-based smartphones and tablets. To distinguish our work from existing ones that rely solely on the GPS technology, we take advantage of the ubiquity of IEEE 802.11 WLAN infrastructure to compliment the "blind spots" of GPS location sensing. Combining the two technologies makes it possible for the personal task reminder to be effective in both indoor and outdoor environments. We also propose two operating models for the personal task reminder to boost the usability of the application. Furthermore, as long as the WLAN infrastructure is available, our work as a foundation of location-based services can easily be extended to be used in many other scenarios, such as guiding in public transportation systems or tourist attractions, location-based learning, and even caring of the Dementia residents.

Guest Editorial: Theme issue on location and context-aware services

Mobile devices, especially smartphones and tablets, are becoming very popular. With the mobile technologies, it is convenient to collect and process data and to provide needed services in real time. Nowadays, people are accustomed to using a smartphone or a tablet to handle the matters in daily life. For example, online payment, personal financial management, social interaction, etc. Besides these well-accepted applications, we believe that services based on location data and context information will play a more important role in the near future. Thus, this theme issue aimed at attracting original and significant research on systems and services that sense, filter, and utilize the location of contextual information on mobile devices. Authors with relevant papers from the AINA-2012 conference (the 26th IEEE International Conference on Advanced Information Networking and Applications) were invited to extend their papers for this theme issue. In addition, an open call for papers was also announced and circulated. At the end of the review process, we accepted seven papers for this theme issue. Each of the papers was peer reviewed by at least two experts in the field. The seven selected papers cover state-of-the-art research issues of location and context-aware services. In the following, we briefly introduce these papers. The first paper titled ‘‘Effects of Population Size for Location-aware Node Placement in WMNs: Evaluation by a Genetic Algorithm Based Approach’’ by Oda et al. uses the genetic algorithm in optimizing the deployment of mesh routers and mesh clients in wireless mesh networks (WMNs). WMNs can serve as an infrastructure for advanced location-aware services. To efficiently support such services and to offer QoS, the placement of mesh router nodes needs to be optimized. Such optimized mesh node distribution can keep the rate of location updates low and support location service managed in the mesh well. The second paper titled ‘‘Hybrid Indoor and Outdoor Location Services for New-Generation Mobile Terminals’’ by Ficco et al. proposes a ubiquitous positioning system of mobile devices in both indoor and outdoor environments. It proposes a hybrid approach that can automatically switch among multiple positioning technologies, while the mobile device is moving. The location services combine signal strength-based fingerprinting techniques for indoor positioning with traditional GPS-based positioning for the outdoor localization. Opportunistic technology switching is performed according to a count-and-threshold mechanism. The third paper titled ‘‘A Connectivity Index for Moving Objects in Indoor Cellular Space’’ by Alamri et al. focuses on indoor positioning of moving objects. The author proposes a new index structure based on the connectivity between the environment cells for moving objects. The index can effectively respond to the spatial indoor queries and enable efficient updates of the location of a moving object in indoor space. The proposed indoor tree performs very well in an empirical study. The fourth paper titled ‘‘A Location-based Personal Task Reminder for Mobile Users’’ by Lin and Hung presents an electronic task reminder based on the calendar in smartphones. In many situations, tasks are only meaningful to be performed at a specific location. This task reminder is triggered by location of the mobile user, not by time as most of other reminder services. This work takes advantage H. Hsu (&) Tamkang University, New Taipei City, Taiwan e-mail: h_hsu@mail.tku.edu.tw

Redesign of an Electronic Clinical Reminder to Prevent Falls in Older Adults

Falls are the leading cause of unintentional injury among US older adults. Guidelines recommend screening patients for fall risk, and providing exercise for patients with gait and balance problems. We redesigned an electronic clinical reminder to improve identification and management of Veterans at high risk for falls, and piloted the reminder in 3 Veterans Health Administration community-based outpatient clinics. This project had 5 key elements: (1) case finding, (2) efficient collection of condition-specific clinical data, (3) clinical reminders to prompt appropriate care, (4) patient and family education materials, and (5) primary care provider (PCP) decision support/PCP and staff education. We reviewed clinical reminder reports, interviewed nurses and PCPs, directly observed clinic operations, and watched nurses and PCPs use the clinical reminder with a dummy patient record to determine areas in need of improvement. Over a 1-year period, 2943 Veterans aged 75 years and older visited the 3 clinics, with 2264 screened for fall risk by the intake nurse, yielding 472 positive screens. PCPs completed gait, balance, and strength evaluations on 231 screen-positive Veterans. Among the 162 Veterans who had a gait, balance, or strength problem on evaluation and were free of advanced dementia or poor prognosis, 39 were offered physical therapy or exercise. PCPs and nurses held divergent opinions about the clinical reminder and the project, with PCPs more negative and nurses more positive. A fall prevention clinical reminder can be incorporated into routine care, but low referral rates to exercise programs suggest that further quality improvement cycles are needed.

A randomized trial of automated electronic alerts demonstrating improved reimbursable anesthesia time documentation

Study Objective: To investigate whether alerting providers to errors results in improved documentation of reimbursable anesthesia care.Design: Prospective randomized controlled trial.Setting: Operating room (OR) of a university hospital.Interventions: Anesthesia cases were evaluated to determine whether they met the definition for appropriate anesthesia start time over 4 separate, 45-day calendar cycles: the pre-study period, study period, immediate post-study period, and 3-year follow-up period. During the study period, providers were randomly assigned to either a control or an alert group. Providers in the alert cohort received an automated alphanumeric page if the anesthesia start time occurred concurrently with the patient entering the OR, or more than 30 minutes before entering the OR.Measurements: Three years after the intervention period, overall compliance was analyzed to assess learned behavior.Main Results: Baseline compliance was 33% ± 5%. During the intervention period, providers in the alert group showed 87% ± 6% compliance compared with 41% ± 7% compliance in the control group (P < 0.001). Long-term follow-up after cessation of the alerts showed 85% ± 4% compliance.Conclusions: Automated electronic reminders for time-based billing charges are effective and result in improved ongoing reimbursement.

VA Hospital Cardiac Electronic Clinical Guideline Reminder Outcomes

U.S. Department of Veterans Affairs (VA) physicians receive guideline reminders to prescribe medications to patients recuperating from cardiac surgery. We examined whether these electronic clinical reminders were associated with a) medication fill rates and b) 6-month risk-adjusted survival after coronary artery bypass graft (CABG) surgery. This retrospective cohort study analyzed the national VA Pharmacy Benefits Management System and the Continuous Improvement in Cardiac Surgery Program data from 10/1/1999 to 9/30/2005. Medication fill rates for a 6 month period prior to the active use of the electronic clinical reminder were compared with fill rates for a 12 month period after electronic reminder use. We found no significant difference in fill rates between the pre- and post-reminder periods. An analysis of variance (ANOVA) model tested whether medication fill rates were affected by electronic reminders. Apparent differences in fill rates before and after implementing clinical reminders disappeared after controlling for multiple comparisons using false discovery rate; therefore data was pooled across years (antihypertensive medications (AH), p = 0.80 and lipid-lowering agent medication (LL), p = 0.30). Changes in fill rates for AH and LL were similar to each other (p = 0.37). A Cox Proportional Hazard Regression model was used to determine the predictors of survival between the 6-month time period prior to the clinical reminder versus the 6-month time period after the reminder was actively used. The clinical reminders for both AHM and LLA were not significantly associated with survival (p = 0.45, hazard ratio = 2.2, confidence intervals 0.29-16). These results do not support the use of electronic clinical reminders in this setting. Instead, these findings support questioning the utility of individual electronic record clinical reminders.

AUtomated Risk Assessment for Stroke in Atrial Fibrillation (AURAS-AF) - an automated software system to promote anticoagulation and reduce stroke risk: study protocol for a cluster randomised controlled trial

BackgroundPatients with atrial fibrillation (AF) are at significantly increased risk of stroke. Oral anticoagulants (OACs) substantially reduce this risk, with gains seen across the spectrum of baseline risk. Despite the benefit to patients, OAC prescribing remains suboptimal in the United Kingdom (UK). We will investigate whether an automated software system, operating within primary care electronic medical records, can improve the management of AF by identifying patients eligible for OAC therapy and increasing uptake of this treatment.Methods/DesignWe will conduct a cluster randomised controlled trial, involving general practices using the Egton Medical Information Systems (EMIS) Web clinical system. We will randomise practices to use an electronic software tool or to continue with usual care. The tool will a) produce (and continually refresh) a list of patients with AF who are eligible for OAC therapy - practices will invite these patients to discuss therapy at the start of the trial - and b) generate electronic screen reminders in the medical records of those eligible, appearing throughout the trial. The software will run for 6 months in 23 intervention practices. A total of 23 control practices will manage their AF register in line with the usual care offered. The primary outcome is change in proportion of eligible patients with AF who have been prescribed OAC therapy after six months. Secondary outcomes are incidence of stroke, transient ischaemic attack, other major thromboembolism, major haemorrhage and reports of inappropriate OAC prescribing in the data collection sample - those deemed eligible for OACs. We will conduct a process evaluation in parallel with the randomised trial. We will use qualitative methods to examine patient and practitioner views of the intervention and its impact on primary care practice, including its time implications.DiscussionAURAS-AF will investigate whether a simple intervention, using electronic primary care records, can improve OAC uptake in a high risk group for stroke. Given previous concerns about safety, especially surrounding inappropriate prescribing, we will also examine whether electronic reminders safely impact care in this clinical area.Trial registrationhttp://ISRCTN 55722437

Management of Forgotten Ureteral Stents

Dear Editor, We read with great interest the study reported by Rabani (1). The author reported their experiences in endoscopic management of forgotten ureteral stents with large burden stone encrustation. As the author stated, ureteral stents are widely used in urology practices. However, complications including migration, fragmentation, and encrustation can be related to stents and sometimes the stents may possibly be forgotten. We would like to add some additional comments and suggestions on the issue of forgotten ureteral stents. Although ureteral stents have various advantages, forgotten stents are a challenging situation even for the experienced endourologists. Forgotten stents can result in serious morbidity, mortality, and an increased financial burden for health services (2). Forgotten ureteral stents usually arise from poor compliance of the patient or failure of the physician to adequately counsel the patient. One important medicolegal issue also needs to be emphasized. The attending urologist is ultimately responsible for the removal of stent and also responsible for the complications if the patient with stent is lost to follow-up. Gravas et al. (3) underscored some important points in the management of forgotten ureteral stents. They reported that a thorough, preoperative, imaging evaluation is necessary to decide the treatment strategy, which should aim to keep the number of necessary interventions as low as possible. They also stated that the most controversial and difficult part in the management of forgotten ureteral stents is the encrusted upper curl, and the critical question is which method out of percutaneous nephrolithotomy, ureteroscopy and extracorporeal shockwave lithotripsy is the most appropriate. As Rabani (1) mentioned, while endourological manage¬ment of these stents achieves success in majority of cases with minimal complications, the best treatment would be prevention of this complication. For achieving this important goal, some investigators have offered different strategies. Lynch et al. have suggested an electronic stent extraction reminder facility recall base to prevent forgot¬ten stents (4). Sancaktutar et al. Described and presented the initial results of a computer-based system that tracks ureteral stents and automatically sends a reminder through a short message service to both the patient’s and the urologist’s mobile phones (2). Recently, Chew et al. even described a novel biodegradable ureteral stent in a porcine model (5). Although endourologic management of forgotten ureteral stents possible in most of the cases with success, further efforts and studies must be made for prevention strategies and possibilities for new kind or type of ureteral stents.

Medication adherence in asthma patients

Although current asthma guidelines stress the importance of assessing and enhancing adherence to asthma treatment, medication adherence rates in asthma patients are consistently low in practice. In this review, we summarize current literature on method of measurement, prevalence, outcome and intervention of medication adherence in asthma patients. Nonadherence to prescribed treatment continues to be a frequent problem in patients with asthma even in recent years. Objective measurement of adherence should be implemented whenever possible. Review of pharmacy refill data or electronic monitoring of inhaler actuation may be a preferred method to assess adherence. Educational programmes should be specifically designed to address the unmet need and specific reasons for nonadherence for the target population. Large, well designed clinical trials to assess the efficacy of remote electronic monitoring and reminder systems to improve adherence are needed. There is an urgent clinical need for systematic, proven methods to assess and address medication nonadherence in asthma patients.

Evidence based laboratory medicine for beginners: getting evidence into practice

Laboratory testing is one of the most widely used diagnostic approaches supporting medical decisions, yet evidence demonstrating the impact of laboratory testing on clinical outcomes is limited. This contributes to inappropriate test utilisation that impacts clinical- and costs-effectiveness of care and patient safety. Trainees will discuss at the workshop diagnostic outcome study designs and their limitations. Evidence-based guidelines are expected to close the gap between research and practice and to promote meaningful utilisation of laboratory medicine. The appearance of so many guidelines, however, created a new gap between their development and use and the quality and reliability of guidelines have been challenged. Therefore critical appraisal of guidelines (e.g., with the AGREE instrument, which will be demonstrated at the workshop; www.agreetrust.org/) is essential before recommendations are implemented. Passive dissemination of guidelines is not sufficient; a multifacet-ed and individualised implementation strategy should be employed including educational outreach visits, individually tailored academic detailing, electronic reminder systems, feedback on performance, and participation of doctors and laboratory professionals in pre- and post-analytical quality assessment or test selection and interpretation programmes, and clinical audits. Examples of these initiatives at the laboratory and clinical interface will be demonstrated and case scenarios will be discussed with trainees.

Does the use of an electronic reminder device with or without counseling improve adherence to lipid-lowering treatment? The results of a randomized controlled trial.

Background: Lipid-lowering treatment with statins has proven to be effective in reducing cardiovascular events and mortality. In daily practice, however, adherence to medication is often low and this compromises the therapeutic effect. The aim of this study was to assess the effectiveness of an electronic reminder device (ERD) with or without counseling to improve refill adherence and persistence for statin treatment in non-adherent patients.Methods: A multicenter, community pharmacy-based, randomized controlled trial was conducted in 24 pharmacies in the Netherlands among patients with pre-baseline refill adherence rates between 50 and 80%. Eligible patients aged 65 years or older were randomly assigned to 1 of 3 groups: (1) counseling with an ERD (n = 134), (2) ERD with a written instruction (n = 131), and a (3) control group that received the usual treatment (n = 134).Main outcome measure: refill adherence to statin treatment for a 360-day period after inclusion (PDC360). Patients with a refill rate ≥80% were considered adherent. The effect among subgroups was also assessed.Results: There were no relevant differences at baseline. In the counseling with ERD group 54 of 130 eligible patients received the counseling with ERD. In the ERD group, 117 of 123 eligible patients received the ERD. The proportions of adherent patients in the counseling with ERD-group (69.2%) and in the ERD group (72.4%) were not higher than in the control group (64.8%). Among women using statins for secondary prevention, more patients were adherent in the ERD group (86.1%) than in the control group (52.6%) (p < 0.005). In men using statins for secondary prevention the ERD was found to have no effect.Conclusion: In this randomized controlled trial, no statistically significant improvement of refill adherence was found if an ERD was used with or without counseling. However, in a subgroup of women using statins for secondary prevention the ERD did improve adherence significantly.

We hear and we forget. We see and we remember. How effective is an electronic reminder when it comes to our patient's contact lens compliance?

We hear and we forget. We see and we remember. How effective is an electronic reminder when it comes to our patient's contact lens compliance?

Development of a Screening and Brief Intervention and Referral for Treatment for ED Patients at Risk for Undiagnosed Hypertension: A Qualitative Study

Providing a screening, brief intervention, and referral for treatment (SBIRT) may encourage patients to obtain provider follow-up for definitive evaluation and treatment of undiagnosed hypertension (HTN). The aims of this study were to determine characteristics of an intervention that would persuade patients to follow-up with a primary care physician for further blood pressure (BP) evaluation, and encourage ED clinicians to provide an SBIRT for patients with elevated BP with no known history of HTN. Qualitative methods were used to analyze individual interviews with ED clinicians and patients. Questions focused on participants' opinions of the meaning of elevated BP, and facilitators and barriers to recommending referral for follow-up (clinicians) or facilitators and barriers to making and keeping a follow-up appointment (patients). Three reviewers coded the interviews using grounded theory. Clinicians identified time constraints and patient-specific factors such as difficulty securing follow-up as major barriers. Some clinicians considered an electronic reminder as a potential facilitator to providing counseling. Patients reported family support and information about complications of uncontrolled HTN such as stroke would increase the likelihood of follow-up. Patient-specific barriers to follow-up included inability to obtain time off from work, forgetfulness, and wait time for an appointment. An SBIRT-HTN could be developed to target patients with elevated BP during an ED visit. The intervention must be simple, easy to implement, and include automated processes to remind clinicians to deliver the intervention. The intervention should include a description of the complications of untreated HTN and an outpatient physician referral.

Limitations to implementing alcohol screening with an electronic clinical reminder in the Veterans Affairs health-care system: a qualitative study

Implementation of alcohol screening and brief intervention (SBI) is a prevention priority. The Veterans Affairs (VA) Healthcare System uses a clinical reminder (CR) in the electronic medical record to prompt and document results of screening and trigger a subsequent CR for BI when screening is positive. Although screening rates are over 90%, marked variability in screening quality has been documented. Four researchers observed clinician interactions with CRs during alcohol screening at nine primary care clinics in the northwest US to identify barriers and facilitators to using CRs to implement quality screening. Observers took handwritten notes, which were transcribed and analyzed qualitatively using an a priori coding template adapted during analyses. We observed 58 support staff (25 registered nurses, 26 licensed practical nurses, and seven health technicians) caring for 166 patients. Alcohol screening prompted by the CR was often uncomfortable and of low quality. Clinicians often offered disclaimers prior to screening or made adjustments to how questions were presented, with some citing the sensitive nature of the questions. Verbal screening typically did not include asking questions verbatim. There was substantial variability in methods of conducting screening across clinics, with some using the CR to facilitate in-person screening by interview and others entering patient responses into the CR after completion of a paper-based screen. Although the CR was designed to trigger a subsequent CR for BI when positive, some clinics used paper encounter forms for this. Findings suggest that VA CRs have important limitations as a method of facilitating effective, high-quality alcohol screening. Barriers observed reflect a combination of limitations of CR technology (and the alcohol screening CR specifically), ways the CR was implemented, clinical workflow, complexity of patient needs, and alcohol-related stigma. Future research should address these barriers to effectively implement recommended care.

The effectiveness of interventions using electronic reminders to improve adherence to chronic medication: a systematic review of the literature

Many patients experience difficulties in adhering to long-term treatment. Although patients' reasons for not being adherent are diverse, one of the most commonly reported barriers is forgetfulness. Reminding patients to take their medication may provide a solution. Electronic reminders (automatically sent reminders without personal contact between the healthcare provider and patient) are now increasingly being used in the effort to improve adherence. To examine the effectiveness of interventions using electronic reminders in improving patients' adherence to chronic medication. A comprehensive literature search was conducted in PubMed, Embase, PsycINFO, CINAHL and Cochrane Central Register of Controlled Trials. Electronic searches were supplemented by manual searching of reference lists and reviews. Two reviewers independently screened all citations. Full text was obtained from selected citations and screened for final inclusion. The methodological quality of studies was assessed. Thirteen studies met the inclusion criteria. Four studies evaluated short message service (SMS) reminders, seven audiovisual reminders from electronic reminder devices (ERD), and two pager messages. Best evidence synthesis revealed evidence for the effectiveness of electronic reminders, provided by eight (four high, four low quality) studies showing significant effects on patients' adherence, seven of which measured short-term effects (follow-up period <6 months). Improved adherence was found in all but one study using SMS reminders, four studies using ERD and one pager intervention. In addition, one high quality study using an ERD found subgroup effects. This review provides evidence for the short-term effectiveness of electronic reminders, especially SMS reminders. However, long-term effects remain unclear.

Suitability of an electronic reminder device for measuring drug adherence in elderly patients with complex medication

We evaluated an electronic reminder device for detecting non-adherence in elderly patients with complex medication regimens. Randomly selected, home-living elderly patients were studied. The patients were aged over 65 years and were taking more than four drugs. Patients received an electronic reminder device which contained a GSM communications module. They were visited three times over a one-year period by a nurse who counted their medicine supply. We compared the adherence measured by the electronic device with the actual adherence measured by the pill count. Almost half of the 315 patients dropped out of the study for various reasons, so the calculations were performed on 168 patients. The adherence measured by the electronic reminder system was 79% and was 92% measured by pill count (P<0.0001). The limits of agreement estimated by a Bland-Altman analysis were -57 to +30. We also compared electronically measured adherence at morning/evening intake times with pill count adherence in the morning/evening only. For the pill count, there was almost no difference between morning and evening adherence rates (93%). For electronic measurement, adherence rates were lower in the evening (75%) than in the morning (81%). Electronic reminders were less reliable than the pill count in measuring adherence. However, the electronic system may be a useful supplement to other, more time consuming methods for measuring adherence.