Background/Objectives Polypharmacy and prescribing potentially inappropriate medications (PIMs) are common among older persons. Appropriate prescribing requires robust communication and shared decision making about medications. This study examines the effect of TRIM (Tool to Reduce Inappropriate Medications), a web tool linking the electronic health record (EHR) to a clinical decision support system, on medication communication and prescribing. Design Randomized clinical trial Setting Primary care clinics at a VA Medical Center Participants 128 Veterans age 65 years and older prescribed ≥ 7 medications, randomized to receipt of TRIM or usual care. Intervention TRIM extracts medications and chronic conditions from the EHR and contains data entry screens for information obtained from brief chart review and telephonic patient assessment. These data serve as input for automated algorithms identifying medication reconciliation discrepancies, PIMs, and potentially inappropriate regimens. Clinician feedback reports summarize discrepancies and provide recommendations for deprescribing. Patient feedback reports summarize discrepancies and self-reported medication problems. Measurements Primary: subscales of the Patient Assessment of Care for Chronic Conditions (PACIC) related to shared decision making, clinician and patient communication; secondary: changes in medications. Results While 29.7% of TRIM participants versus 15.6% of control participants provided the highest PACIC ratings, the difference was nonsignificant. Adjusting for covariates and clustering of patients within clinicians, TRIM was associated with significantly more active patient communication and facilitative clinician communication, and with more medication-related communication among both. TRIM was significantly associated with correction of medication discrepancies, but had no effect on number of medications or reduction in PIMs. Conclusions TRIM improved communication around medications and accuracy of documentation. While there was no association with prescribing, the small sample size provided limited power to examine medication-related outcomes.

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Study Objective To create a clinical decision support system (CDSS) for evaluating problems with medications among older outpatients based on a broad set of criteria. Design Web-based CDSS development. Setting Primary care clinics at a Veterans Affairs medical center. Participants Forty Veterans age 65 years and older who were prescribed seven or more medications that included those for treatment of diabetes mellitus and hypertension. Measurements and Main Results The Tool to Reduce Inappropriate Medications (TRIM) uses a program to extract age, medications, and chronic conditions from the electronic health record to identify high-risk patients and as input for evaluating the medication regimen. Additional health variables obtained through chart review and direct patient assessment are entered into a Web-based program. Based on a series of algorithms, TRIM generates feedback reports for clinicians. When used for these Veterans, TRIM identified medication reconciliation discrepancies in 98% (39/40 Veterans), potentially inappropriate medications in 58% (23/40), potential problems with feasibility (based on poor adherence and/or cognitive impairment) in 25% (10/40), potential overtreatment of hypertension in 50% (20/40), potential overtreatment of diabetes in 43% (17/40), inappropriate dosing of renally excreted medications in 5% (2/40), and patient-reported adverse reactions in 5% (2/40). Conclusion This evaluation of TRIM demonstrated that data elements can be extracted from the electronic health record to identify older primary care patients at risk for potentially problematic medication regimens. Supplemented with chart review and direct patient assessment, these data can be processed through clinical algorithms that identify potential problems and generate patient-specific feedback reports. Additional work is necessary to assess the effects of TRIM on medication deprescribing.

BackgroundFrameworks exist to evaluate the appropriateness of medication regimens for older patients with multiple medical conditions (MCCs). Less is known about how to translate the concepts of the frameworks into specific strategies to identify and remediate inappropriate regimens.MethodsModified Delphi method involving iterative rounds of input from panel members. Panelists (n = 9) represented the disciplines of nursing, medicine and pharmacy. Included among the physicians were two geriatricians, one general internist, one family practitioner, one cardiologist and two nephrologists. They participated in 3 rounds of web-based anonymous surveys.ResultsThe panel reached consensus on a set of markers to identify problems with medication regimens, including patient/caregiver report of non-adherence, medication complexity, cognitive impairment, medications identified by expert opinion as inappropriate for older persons, excessively tight blood sugar and blood pressure control among persons with diabetes mellitus, patient/caregiver report of adverse medication effects or medications not achieving desired outcomes, and total number of medications. The panel also reached consensus on approaches to address these problems, including endorsement of strategies to discontinue medications with known benefit if necessary because of problems with feasibility or lack of alignment with patient goals.ConclusionsThe results of the Delphi process provide the basis for an algorithm to improve medication regimens among older persons with MCCs. The algorithm will require assessment not only of medications and diagnoses but also cognition and social support, and it will support discontinuation of medications both when risks outweigh benefits and when regimens are not feasible or do not align with goals.

BackgroundThe US Veterans Administration (VA) has developed a robust and mature computational infrastructure in support of its electronic health record (EHR). Web technology offers a powerful set of tools for structuring clinical decision support (CDS) around clinical care. This paper describes informatics challenges and design issues that were confronted in the process of building three Web-based CDS systems in the context of the VA EHR.MethodsOver the course of several years, we implemented three Web-based CDS systems that extract patient data from the VA EHR environment to provide patient-specific CDS. These were 1) the VACS (Veterans Aging Cohort Study) Index Calculator which estimates prognosis for HIV+ patients, 2) Neuropath/CDS which assists in the medical management of patients with neuropathic pain, and 3) TRIM (Tool to Reduce Inappropriate Medications) which identifies potentially inappropriate medications in older adults and provides recommendations for improving the medication regimen.ResultsThe paper provides an overview of the VA EHR environment and discusses specific informatics issues/challenges that arose in the context of each of the three Web-based CDS systems. We discuss specific informatics methods and provide details of approaches that may be useful within this setting.ConclusionsInformatics issues and challenges relating to data access and data availability arose because of the particular architecture of the national VA infrastructure and the need to link to that infrastructure from local Web-based CDS systems. Idiosyncrasies of VA patient data, especially the medication data, also posed challenges. Other issues related to specific functional needs of individual CDS systems. The goal of this paper is to describe these issues so that our experience may serve as a useful foundation to assist others who wish to build such systems in the future.