Table 1 Provisional and final theories with summary synthesis
Provisional Theory | Articles contributing to theory | Data synthesis summary | Panel Ratings | Final Theory, text in BOLD highlights changes | Relevance of Theory to Stages of PERM |
|---|---|---|---|---|---|
1. Engage Stakeholders | |||||
If users are given the opportunity to provide input, and both give and receive feedback at all stages of the introduction of a PERM system, they will feel engaged, be supportive and understand the challenges, they will then accept and feel confident about using a PERM system to complete MedRec at care transitions | 1, 2, 3, 4, 5, 9, 10,13, 14, 15, 16, 17, 18, 19 | There was a general consensus from the articles that engagement of the stakeholders was important. Elements such as the level of engagement, opportunities to provide feedback in a meaningful way, a bottom up/top down approach allowing cross department discussions, as well as the equal consideration of technology and clinical elements, helped to describe what this engagement should look like. Setting up innovative ways for stakeholders to give feedback throughout the process and showing them how the feedback was used were identified as ways to achieve this engagement | U: 4.5 R: 4.4 P: 3.8 | If stakeholders including all user groups are given the opportunity to provide input, and both give and receive feedback at all stages of the design, implementation and use of PERMs, they will feel engaged, be supportive and understand the challenges, they will then accept and feel confident about using PERMs to complete MedRec at care transitions | Design, implementation and use |
2. Inclusive design | |||||
If a PERM system is developed using user-centered design & usability principles then users will feel heard and supported, thus fostering successful collaboration, acceptance and increased use of the PERM system to complete MedRec at care transitions | 1, 2, 4, 6, 7, 8, 9, 11,15, 16, 17, 18, 19 | The display features, layout and use of abbreviations, and terminology or drug databases were the main topics discussed in the literature in relation to the importance of involving others in collaborative design. Issues such as phasing the introduction of PERMs, considering the electronic systems already in use and the early development of solutions to allow complex systems cater for the needs of multiple users and functions, were all considered to impact on the successful implementation and use of PERMs | U: 4.5 R: 4.5 P: 4.2 | If PERMs are designed with user input and employing user-centered design & usability principles then users will feel heard and supported, thus fostering successful collaboration, acceptance and increased use of PERMs to complete MedRec at care transitions | Design |
3. PERMs complement existing good processes | |||||
If the content of a PERM system replicates MedRec processes and forms that are already in existence in a setting and have been shown to work well, then the PERM will feel familiar and consistent, users will feel confident using it and the PERM will become embedded more easily into normal work practices, allowing a smooth transition to PERM to improve MedRec at care transitions | 4, 6, 8, 12, 13, 14, 15, 18, 19 | The importance of firstly ensuring that the systems being used for Med Rec are fit for purpose before any plans to design the PERMs was stressed in a number of the articles. This includes identifying who is responsible for at each stage of the MedRec process | U: 4.4 R: 3.9 P: 3.5 | If PERMs complement MedRec cognitive and workflow processes or forms that are already in existence in a setting and have been shown to work well, then PERMs will feel familiar and consistent, users will feel confident using it and PERMs will become embedded more easily into normal work practices, allowing a smooth transition to PERMs to improve MedRec at care transitions | Design |
4. Build Trust | |||||
If users are made aware of how others access and use the information on a PERM system, the integrity of the sources of data that populate the PERM and the integrity of how data are protected, their trust and confidence in the system will increase, they will then comprehend how the system aims to work and be more likely to use it at care transitions to improve MedRec and patient safety | 1, 2, 3, 4, 5, 6, 8, 12, 13, 14, 15, 18, 19 | Helping the user to understand the processes or roles of others, the sources, accuracy and safety of the medication data and the reliability of PERMs were shown in the data to impact on the level of trust in PERMs This theory was rated joint lowest for understanding by the panels. Of the panellists who provided some comment in relation to their ratings, some did not understand it and others understood it but did not agree with it, while others agreed with it completely | U: 4.1 R: 4.3 P: 3.9 | If users are aware and understand how they and others access and use PERMs, the integrity of the PERMs data sources and the data protection controls, their trust and confidence in the PERMs design and use will increase, they will then be more likely to value and use it at care transitions to improve MedRec and patient safety | Design, Implementation and Use |
5. Tailored Training | |||||
If training is provided to users that takes into account their existing MedRec knowledge and skills, their computer skills and their role at care transitions, and the training outlines the clear benefits, usefulness and usability of a PERM system, users will then feel less anxious and be more engaged and confident in relation to the introduction of a PERM system in their setting | 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16,17, 19 | There was a general consensus regarding the need for training on any new PERMs. How this training should be tailored to different users was considered in some of the included articles. Making users aware of or reminding them about the impact of poor Med Rec at care transitions and taking into consideration their computer skills were common elements. These knowledge and skills should not be assumed | U: 4.4 R: 3.8 P: 3.6 | No changes made | Implementation |
6. Support and on-demand training | |||||
If training on a PERM system is provided at implementation and continued at regular intervals to cater for new staff or those needing additional support, at times or in formats that suit all users, with the opportunity for users to give feedback and they are given time to become familiar with the system, then the users will feel supported and enabled to use the PERM system consistently thereby improving MedRec at care transitions | 1, 4, 10, 12, 13, 14, 15, 16, 18, 19 | A number of articles highlighted the need for continual or repeat training, catering for the individual needs of staff, to ensure that the standard of Med Rec using PERMs remained consistent. The use of dedicated staff, “super-users” or “champions”, freed from their normal duties, to provide this training and support was also identified. The opportunity for users to provide feedback in relation to the training offered to them was also considered important | U: 4.4 R: 3.6 P: 3.4 | If support and training on PERMs is available on demand to cater for new staff or those needing additional support, at times or in formats that suit all users, with the opportunity for users to give feedback on the training, then the users will feel supported and enabled to use PERMs consistently thereby improving MedRec at care transitions | Use |
7. Interoperability | |||||
If the PERM data sources are technically interoperable with the system, allowing integration of data from multiple sources then users will find the system aligns with or improves the MedRec process flow, thereby increasing their use of PERM for MedRec at care transitions impacting positively on patient safety | 1, 3, 4, 6, 7, 10, 11, 12, 16, 19 | Interoperability was assumed in many of the articles, will little reference to it other than to define it and to acknowledge that the ability to integrate data from multiple sources was important in the usability of PERMs. PERMs must be seen to improve and support the safety and efficiency of MedRec at care transitions | U: 4.6 R: 4.8 P: 4.0 | No changes made | Design |
8. Resource investment | |||||
If the required time and resource intensity of introducing and maintaining a PERM system for MedRec at care transitions is recognised and understood early by organisations and they acknowledge from the outset that it will increase the amount of data gathered, recorded and used, increasing the users’ workload, then organisations will be prepared and budget for the additional resources required | 1, 3, 7, 8, 11, 12, 13, 15, 18 | Some electronic resources have been shown to save money in the long run, for example e-prescriptions, this is not the case with MedRec. As reported in a number of the articles, improvement comes with a price; improving MedRec at care transitions increases the effort, volume and quality of data gathered which provides new opportunities for risk identification, management and analysis, resulting in the need for additional staff to carry out all of these elements and the budget to pay for them | U: 4.1 R: 4.2 P: 2.9 | If the increased effort, volume and quality of data gathered when using PERMs for MedRec at care transitions, providing opportunities for risk identification, management and analysis, is recognised by leaders/ management from the outset then they will understand the need for additional resourcing to support the use of PERMs to improve MedRec at care transitions and patient safety | Design, Implementation and Use |
9. Positive impact of Legislation or Governance | |||||
If the introduction of a PERM system or standards for the MedRec process is supported by relevant legislation, governance or policies then organisational participation and engagement is increased impacting positively on individual users' engagement with the introduction of a PERM system to improve MedRec at care transitions | 1, 2, 3, 4, 6, 7, 8, 10, 11, 12, 13, 16, 18, 19 | The existence of legislation or governance was seen mainly as a positive influence in the articles. However, if the legislation or governance was slow to adapt to changes, for example in the expanding role of healthcare workers in the MedRec process, it could have a negative influence | U: 4.5 R: 4.2 P: 3.7 | No changes made | Implementation |
10. Patients as users of a PERM | |||||
If patients are supported to use PERM to understand and record their medication use and share their medication information, they will feel enabled, empowered and organised in helping to maintain an accurate medication record, be more informed and have improved likelihood of adherence to their medications | 1, 2, 6, 7, 8, 9, 11, 12, 13, 17, 19 | There were conflicting opinions in relation to the role patients could play in Med Rec using PERM, with some authors in full support of their role while others had concerns. The main issues identified by healthcare workers were the accuracy of data supplied by patients and their ability to use technology. There were a small number of articles included in the review that dealt with this issue from the patient’s perspective. For the most part, patients were positive about the use of PERM for their health information, reporting increased understanding about their medications and improved adherence | U:4.6 P: 4.6 P: 3.9 | No changes made | Design, implementation and Use |