Personal Electronic Records of Medications (PERMs) for medication reconciliation at care transitions: a rapid realist review

Background Medication reconciliation (MedRec), a process to reduce medication error at care transitions, is labour- and resource-intensive and time-consuming. Use of Personal Electronic Records of Medications (PERMs) in health information systems to support MedRec have proven challenging. Relatively little is known about the design, use or implementation of PERMs at care transitions that impacts on MedRec in the ‘real world’. To respond to this gap in knowledge we undertook a rapid realist review (RRR). The aim was to develop theories to explain how, why, when, where and for whom PERMs are designed, implemented or used in practice at care transitions that impacts on MedRec. Methodology We used realist methodology and undertook the RRR between August 2020 and February 2021. We collaborated with experts in the field to identify key themes. Articles were sourced from four databases (Pubmed, Embase, CINAHL Complete and OpenGrey) to contribute to the theory development. Quality assessment, screening and data extraction using NVivo was completed. Contexts, mechanisms and outcomes configurations were identified and synthesised. The experts considered these theories for relevance and practicality and suggested refinements. Results Ten provisional theories were identified from 19 articles. Some theories relate to the design (T2 Inclusive design, T3 PERMs complement existing good processes, T7 Interoperability), some relate to the implementation (T5 Tailored training, T9 Positive impact of legislation or governance), some relate to use (T6 Support and on-demand training) and others relate iteratively to all stages of the process (T1 Engage stakeholders, T4 Build trust, T8 Resource investment, T10 Patients as users of PERMs). Conclusions This RRR has allowed additional valuable data to be extracted from existing primary research, with minimal resources, that may impact positively on future developments in this area. The theories are interdependent to a greater or lesser extent; several or all of the theories may need to be in play to collectively impact on the design, implementation or use of PERMs for MedRec at care transitions. These theories should now be incorporated into an intervention and evaluated to further test their validity. Supplementary Information The online version contains supplementary material available at 10.1186/s12911-021-01659-8.


Citations of Interest
Any references that might yield additional data 15 29 Content of PERM What information is available on the PERM 2 2 Barriers Any stated perceived or actual barriers in relation to what content needs to be on the PERM or content that is on the PERM but has issues. Realist Outcomes Not the formal outcomes stated by the researchers, but the Realist outcomes, relating to how the context and mechanisms created these outcomes, unexpected outcomes, these may overlap with the formal outcomes. Sources and references from the HIQA policy documents relating to the ten theories for the Irish context.

NAME DESCRIPTION SOURCES REFERENCES
Theory 1 Stakeholder Engagement 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, understand the challenges, be accepting and feel confident about the introduction of a PERM system.

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Theory 2 Collaborative Design If a PERM system is designed with user input, in relation to the display features and ease of use, with a balanced selection of Alerts or Warnings suitable to the setting, considers terminology issues, shows how complex issues will be dealt with early in the process and how user feedback has been taken on board, then users will feel heard and supported, thus fostering successful collaboration and acceptance of the PERM system.

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Theory 3 Base PERM on existing tried and tested processes If the content of a PERM system replicates Med Rec processes and forms that are already in existence in a setting, that 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 Med Rec at care transitions.

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Theory 4 Build Trust If users are made aware of how others access and use the information on a PERM system, the sources of data that populates the PERM and how data is protected, their trust and confidence in the system will increase and they will comprehend how the system aims to improve patient safety and MedRec at care transitions.

Theory 5 Tailored Training
If training is provided to users that takes into account their existing knowledge of Med Rec at care transitions and their computer skills, and the training outlines the clear benefits, usefulness and usability of a PERM system, they will feel less anxious, be more engaged and confident in relation to the introduction of a PERM system in their setting.

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Theory 6 Available and repeat 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, is available 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 Med Rec at care transitions.

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Theory 7 Resource Investment The interoperability of a PERM system for Med Rec at care transitions increases the amount of data gathered, recorded and used. If organisations are made aware and acknowledge from the outset that this will impact on the workload of the users and understand the health economic value of a PERM system, they will be prepared for the additional resources required, which will improve access and organisation of data in a useful and useable format, facilitate more informed decision making, reduce errors, reduce 7 105 Theory 8 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 Med Rec at Care Transitions.

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Theory 9 Patients as users of a PERM If patients are provided with education in relation to the purpose and importance of adherence to their medications and are given training on the use of a PERM to support that, they will feel enable, empowered and organised in relation to playing a role in the maintenance of an accurate record of their medications, be more informed and have improved adherence to their medications impacting positively on their health.
Theory 10 Interoperability (Added after pilot) 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 the MedRec process flow and see the benefits, thereby increasing their use of PERM for MedRec at care transitions impacting positively on patient safety.