Contribution of Different Patient Information Sources to Create the Best Possible Medication History.

Area of Science:

• Health Informatics
• Clinical Pharmacy
• Patient Safety

Background:

• Accurate medication history is critical for effective medication reconciliation.
• Evaluating data sources like patient interviews, hospital records, and shared electronic health records (SEHR) is essential.

Purpose of the Study:

• To assess the contribution of patient/caregiver interviews, hospital medical records, and SEHR to an accurate best possible medication history.
• To determine the optimal data retrieval period from SEHR for medication history.

Main Methods:

• Observational cross-sectional study including adult patients on medication.
• Reconciliation of patient interviews with hospital medical records and SEHR.
• Analysis of SEHR data from 3, 6, 9, and 12-month periods.

Main Results:

• Only 29% of medications were found across all three sources (patient, hospital, SEHR).
• SEHR provided 40% of medication data not found in other sources.
• SEHR data retrieval increased with longer time periods, with 1933 medications at 12 months versus 778 at 3 months.

Conclusions:

• SEHR significantly supplements patient interviews and hospital records, capturing omitted medication data.
• Utilizing SEHR data from the preceding six months is the most efficient method for establishing a best possible medication history.
• SEHR should be the primary supplementary source for improving medication history accuracy.