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. 2025 May 6:27:e70133.
doi: 10.2196/70133.

Identifying Medication Review Topics to Be Documented in a Structured Form in Electronic Health Record Systems: Delphi Consensus Survey

Tanja Lindholm  1 , Noora Lias  1 , Kirsi Kvarnström  1   2   3 , Anna-Riia Holmström  1 , Terhi Toivo  1   4 , Marjo Uusitalo  5   6 , Harri Nurmi  7 , Marja Airaksinen  1
Affiliations

Identifying Medication Review Topics to Be Documented in a Structured Form in Electronic Health Record Systems: Delphi Consensus Survey

Tanja Lindholm et al. J Med Internet Res. .

Abstract

Background: Poor data transfer and interoperability between electronic health record (EHR) systems has been a challenge hindering availability and usability of patient information in clinical practice and evidence-based decision-making. To improve data transfer and interoperability, patient information should be documented in a structured format. This also applies to medication-related patient information and results of the interventions, such as medication reviews (MRs), to individually optimize medication regimens, especially in older adults.

Objective: This study aimed to identify what information obtained from MRs should be documented in a structured form in EHRs at a national and organizational level.

Methods: The study was conducted as a 3-round Delphi consensus survey in 2020. The electronic survey was based on a comprehensive inventory of international and national MR procedures in various settings. Expert panelists (N=41) independently assessed which topics should be documented in a structured form in EHRs. The interprofessional panel (N=41) consisted of 12 physicians, 13 pharmacists, 10 nurses, and 6 information management professionals (participation rate 66%-76% in rounds 1-3; consensus limit set at 80%). The responses were analyzed quantitatively and qualitatively.

Results: Consensus was reached on 97.3% (108/111) of predetermined topics to be documented in a structured form in EHRs. Of these, 39 concerned the MR process, 25 related to potentially drug-induced symptoms, 11 related to burden of risks for adverse drug effects, 12 related to laboratory tests and other test results, 12 related to medication adherence, and 9 related to the use of intoxicants. The patient's blood pressure (mean 4.85, SD 0.53; on a Likert scale 1-5), kidney function (mean 4.81, SD 0.56), and risk of bleeding (mean 4.81, SD 0.56) were ranked as the 3 most important topics to be documented in a structured form. The panel reached a consensus that the information obtained from MRs should be made available to all health care professionals in the national digital repository for patient data and to patients to some extent.

Conclusions: The interprofessional expert panel strongly agreed on the results of the MRs that should be documented in a structured form in EHRs and made available to both health professionals involved in care teams and patients themselves.

Keywords: electronic health record; information management; medical informatics; medication information; medication review; patient information; structured documentation.

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Conflict of interest statement

Conflicts of Interest: None declared.

Figures

Figure 1
Figure 1
The study outline aimed at identifying medication review topics to be documented in a structured form in electronic health records.
Figure 2
Figure 2
The distribution of medication review topic input by category for Delphi rounds 1 to 3. Rating the importance of the topics in the third Delphi round was conducted on a Likert scale 1 to 5 (5: important topic, 4: moderately important topic, 3: cannot say, 2: moderately unimportant, and 1: unimportant topic). EHR: electronic health record.
Figure 3
Figure 3
A summary of the results of the Delphi rounds 1 to 3. One of the medication review process topics (duration of drug treatment) was not prioritized in the third round due to technical issues.
See this image and copyright information in PMC

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