Citation: Ulmer, I., Mildner, C., Krämer, I.: "Intersectoral use of the nationwide medication plan - multicenter feasibility study among patients, pharmacists and doctors in Rhineland-Palatinate" in "Monitor Healthcare Research" (01/20), p. 55- 60, doi: 10.24945/MVF.01.20.1866-0533.2203

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>> The aim of the prospective study was to examine the feasibility, practicality and acceptance of the internet-based, intersectoral use of the BMP among doctors, pharmacists and patients in Rhineland-Palatinate. In addition, the influence of the BMP on patients' knowledge of their drug therapy and drug therapy safety should be examined. The interdisciplinary use of the eBMP proved to be a suitable instrument for improving drug therapy safety (10). The feasibility, practical suitability and acceptance of the eBMP are reported here.
methods
Study design
The patient study was carried out as a prospective, multicenter, non-comparative study between March 2015 and September 2016 with BMP version 2.0 from December 16, 2014 in patients, hospitals, general practitioners and regular pharmacies in Rhineland-Palatinate. There was a positive vote from the ethics committee of the state medical association and the data protection officer of the state of Rhineland-Palatinate. All participants gave written consent to participate. Inpatient patients aged ≥18 years with ≥3 AM in long-term therapy were eligible as study participants (for further inclusion/exclusion criteria see (10)). The study was led by the pharmacy of the Mainz University Medical Center. The hospitals participating as recruitment centers are shown in Fig. 1. If they were interested in taking part in the study, the patients named their family doctor and regular pharmacy. Inclusion in the study took place after written consent from the patient, family doctor and/or regular pharmacy.
When the patient was included in the study, a pharmaceutical drug history was carried out by a hospital pharmacist as a data basis for the initial electronic BMP. Upon discharge, the eBMP was created in close consultation with the hospital doctor and based on the last medication ordered and recommended in the discharge letter (for example, see Fig. 2). The hospital pharmacist advised the patient on his medication and how to use the printed eBMP. For 6 months after discharge from the hospital, the family doctor/main pharmacy should update the eBMP in the online medication plan portal and print it out for the patient.

Primary and secondary outcome measures
The primary outcome measure was the timeliness of the eBMP at the end of the study (6 months per patient). This was defined as the agreement in terms of content of the eBMP last saved in the portal with the current medication according to patient information, which was recorded using the “Patient Knowledge” questionnaire. On the specially established questionnaire, patients should enter the names of their AM as well as the potency, times of use, instructions for use and reasons for taking it. Sending a BMP instead of a completed questionnaire as well as informal lists were permitted. An MP from the general practitioner's practice software that did not correspond to the structure of the BMP was rated as no information (n/a). A medication plan was only considered current if all AMs matched in type and number. The number and percentage of patients with missing or different information were calculated.
The secondary outcome measures were analyzed from the medication plan portal and from the questionnaires. The feasibility was measured in the form of the degree of use (frequency of changes, change, replacement
reason), carrying of the printed BMP by the patient and time expenditure analyzed. The practical suitability (suitability as a means of communication, content, structure) and acceptance (need, importance of BMP for patients, indication of instructions and reasons for taking it) were recorded using a questionnaire.

Medication plan portal
Since the specification-compliant format of the BMP was the subject of the investigation, a primary system-independent Internet portal for the creation, management and printing of the eBMP was developed by Moysies & Partner IT- und Managementberatung mbB, Eltville. The only technical requirement for access to the eBMP portal was internet access and access data. Only the combined entry of the access data (PIN) from the pharmacy or doctor and the patient allowed access to the respective patient's data. All created eBMPs were saved for later analysis.

Questionnaire on practical suitability and acceptance
The participating patients, pharmacists and general practitioners were surveyed by the hospital pharmacists using a target group-specific questionnaire about the acceptance and practicality of the eBMP (patients 2 weeks, 6 months after hospital discharge; doctors, pharmacists after 6 months). At the time of each survey, the questionnaires were sent with a prepaid return envelope. A telephone interview was also possible for patients. The answer options were yes/no or a 4-part Likert scale. If several answers were ticked or a question was not answered, this was considered as no answer (n/a).

Statistical analyses
For the primary objective “Currentness of the eBMP” the relative frequency including 95% confidence interval (binomial distribution, Clopper-Pearson) is calculated. For sample size planning (n = 500-600), it was assumed that around 40-50% of patients would fill out and return the “Patient Knowledge” questionnaire. With approximately 20% of patients with current BMP after 6 months, the confidence interval should be between 0.15 and 0.25 with a certainty of 95%. The answers at the different survey times are compared using the McNemar test. For questions that had to be answered with a 4-point Likert scale, a dichotomization into agreeing (exactly true/agree) and disagreeing (rather disagree/disagree) was necessary. All tests carried out are exploratory, no statement of significance is intended and p-values are interpreted purely descriptively. Using logistic regression
become factors influencing the return of the questionnaire
Patient knowledge and the timeliness of medication plans are examined. The evaluations were carried out using “IBM” SPSS Statistics versions 23 & 24 and “Microsoft” Excel 2010 version 14.
Results
896 patients were approached in the participating clinics, of which 601 (67%) surgical and internal medicine patients took part in the study. Reasons for non-participation included, for example, “no interest” on the part of the patient (30%) or the unwillingness of 348 general practitioners and 45 regular pharmacies (10%) to participate. The average patient age was 68 years; men were slightly overrepresented with a proportion of 60%.
The patients were cared for on an outpatient basis by 189 general practitioners and 327 regular pharmacists, with optimal joint care provided by the general practitioner and pharmacy for 38% of the patients. Most general practitioners (77%) and regular pharmacies (59%) only cared for one study patient each (range 1-6 per practice, 1-11 per pharmacy).
During the entire study period, 2,199 medication plans with 23,479 medication entries were created, of which 601 eBMPs were created for inpatient admission and discharge with an average of 8 or 9 AM. During outpatient treatment, the eBMP was updated for 234 of the 601 patients (39%). The eBMP was updated for an average of 35 patients per month during the course of the study. This resulted in 997 medication plans with an average of 13 AM (10.5 AM prescribed by a doctor, 1.4 AM prescribed for a limited time, 1.2 AM self-medication). Self-medication was used by 29% patients (173/601). The proportion of the total medication was 6.2% (1,467/23,479). As expected, the majority of self-medication entries (79%) were eBMPs created in the outpatient setting.
The level of updating was highest for patients who were cared for jointly by their family doctor and regular pharmacy (47%). The time required for doctors and pharmacies was around 10 minutes. The time required for hospital pharmacists was around 30 minutes per medication plan and included a pharmaceutical medication analysis.
Presence of a current eBMP at the end of the study (primary outcome measure)
The response rate for the “Patient Knowledge” questionnaire was 46%
(276/601) with 1,979 medication entries. Only 37 patients (13.4%
[37/276]; 95% CI: 9.6%-18.0%) had a current BMP after 6 months. If the entries were more than 20%, the patients did not specify the potency and in 8% it was different from the eBMP. The information on 14% did not match when it was taken. In 23 of the 37 patients (62%), the BMP created at hospital discharge was still current. Instructions for taking the medication and reasons for taking it were missing in half of the entries. Using logistic regression, no connection could be determined between the age, gender or care relationship of the patients and the presence of a current eBMP at the end of the study or the return of the “Patient Knowledge” questionnaire.

Practical suitability and acceptance of the eBMP from the patient's perspective
Two weeks and six months after hospital discharge, 64% and 50% of the patients answered the corresponding questionnaire. The results of selected questions are shown in Table 1. Age, gender and number of medications at discharge had no influence on the answers to the questions.
When visiting a doctor or pharmacy, 40% of patients presented the printed eBMP; when they were readmitted to the hospital, 37% (25/67 patients). The level of use of the printed eBMP in the form of carrying it with you during doctor/pharmacy visits reduced over time from 63% to 43% (McNemar test: p<0.001). At both survey times, the patients considered the BMP at ≥95% to be helpful. Significantly more than 80% or 90% of the patients surveyed found it important to state the reason for taking the medication or the instructions for taking it for their AM on the BMP. Two thirds of the patients were able to improve their knowledge of prescribed medicines using the MP at both times of the survey. The patients confirmed an increase in their knowledge of how to take their medications correctly and why they were taken. Most patients confirmed that the BMP had a clear structure (see Table 1).

Practical suitability and acceptance of the eBMP from the perspective of general practitioners/main pharmacies
35% (66/189) of the participating general practitioners and 46% (151/327) of the participating pharmacies took part in the evaluation of the eBMP using a questionnaire. The results of selected questions are shown in Table 2. 79% of general practitioners and 73% of pharmacies stated that they created an MP for their patient whenever there was a change in medication. From this, the acceptance and feasibility of creating the eBMP can be derived. Doctors and pharmacists supported the inclusion of instructions and reasons for taking the medication on the BMP and confirmed that patients are better informed about their drug therapy through the BMP.
The content and structure of the BMP were rated as sufficient and clear by both professional groups. The general practitioners confirmed improved communication with hospital doctors using the eBMP and welcomed receiving information on specialist prescriptions and self-medication through the BMP. 80% of pharmacists valued the BMP as a support for clarifying ambiguities in prescriptions. The BMP thus proved to be a practical means of communication.
discussion
The eBMP was tested for the first time across sectors using various methods on a large number of 600 patients, five hospitals and more than 500 non-preselected doctors and pharmacies. The participants' catchment area represented both rural and urban infrastructure. At the start of the study, there was no suitable software available to create the BMP in hospitals/practices and pharmacies. The participants were networked via a new online portal and were able to test its use. They were also able to use specially created value catalogs for the “reasons/indications” fields with standardized and patient-friendly terms. As a result of this information, more than two thirds of the patients had an increase in knowledge, which is seen as a contribution to improving drug therapy safety. Many pharmacies have added self-medication. The feasibility proved to be given within a reasonable amount of time. The internet-based version of the eBMP represents a suitable information carrier at inter- and intra-sectoral interfaces.
However, after 6 months, only 13% of the patients who answered the corresponding questionnaire had a current eBMP. The method for checking timeliness proved difficult. The comparison of the medication in the most recently created eBMP with the patient information does not allow any conclusions to be drawn about the accuracy of the information provided, but only considers their consistency. In the literature, the agreement rate between medical medication data/medication plans and patient information varies between 6.5% and 78% (11-15).
The survey of patients, doctors and pharmacists revealed large majorities about the practical suitability and acceptance of the eBMP. The healthcare professionals valued the eBMP as an intersectoral and interprofessional communication medium. The gain in information regarding prescriptions from co-treating doctors or self-medication was particularly rated as positive. Since less than half of patients inform their doctor about the self-medication they use (16), it is advisable that this is entered into the eBMP when purchased from the pharmacy and taken into account when checking for interactions or adverse drug events. The reserved use of the specially established online portal by general practitioners contradicts the survey results. It is most likely due to the unfamiliar information technology and lack of interoperability of the information systems, especially since one
Remuneration was granted and informed in advance (17,18). The main points of criticism (lack of integration, patient PIN, time
effort) refer to
the technology, not the BMP itself. The planned availability of the eBMP on the health card must urgently be considered as a first step towards digitized medical-pharmaceutical information and
Communication can be implemented.
The study participants were older patients with below-average quality of life (survey not shown here). We attribute the older age of the participating patients compared to the general German population (19.20) to the inclusion criteria (hospital stay, long-term medication ≥ 3 AM). It cannot be ruled out that patients with a lower quality of life responded disproportionately often or were included in the study.
The patients confirmed that the BMP supports them in dealing with their AM and a great increase in knowledge regarding the reasons/indications for taking their medicines. Even if these parameters are not mandatory to be included in the eBMP, this is strongly recommended in order to strengthen patient competence. There is an urgent need for nationwide catalogs of values and their integration into the practice/pharmacy management systems. In addition, it is not enough that an eBMP exists, it must be up-to-date and the information it contains must (be able to) be used by everyone involved to improve drug use and safety. To do this, the digital creation and maintenance of the BMP must be promoted in the hospital, doctor and pharmacy management systems. <<