How Does the Electronic Collection of Patient-Reported Outcomes Improve Patient Engagement in Pharmacy Encounters? A Multi-Method Study

1. Background

Patient-reported outcomes (PRO) are patients’ reports of how they feel, think, and function with regard to their health without the interpretation of clinicians [1]. The collection of PRO in healthcare settings is associated with better symptom monitoring, shared decision-making, and tailored patient care [2]. Acknowledging the value of routine collection of PRO, regulatory and federal agencies such as the Agency for Healthcare Quality and Research and The Office of the National Coordinator for Health Information Technology consider research related to patient-generated health data among their top priorities [3,4].

As community pharmacists are at the forefront of the healthcare system and have more frequent interactions with patients, using electronic PRO tools in pharmacies holds a significant advantage for both patients and pharmacists. In the fast-paced pharmacy environment, patients can share their medication experiences efficiently and be more involved in the counseling [5]. PRO tools can support pharmacists’ roles through early identification and management of medication-related problems, eventually leading to improved medication adherence and health outcomes. Additionally, they can overcome barriers to effective patient-pharmacist interaction, such as limited time and lack of privacy [6]. Although the utilization of PRO to guide the management and monitoring of health conditions is not new in pharmacy-related research, little research has evaluated how integrating PRO into medication consultations can influence the interaction between patients and pharmacists [7-9].

Using a randomized controlled design, we explored the impact of RxTalk™, a tablet-based PRO tool, on patient-pharmacist interaction in a community pharmacy setting that wished to try out a new service to improve the quality of pharmacy consultations [10]. Patients in the intervention group used RxTalk™ before medication consultations, while those in the control group received standard care and did not use RxTalk™. After intervention patients completed the questions in RxTalk™, the researcher copied key information from RxTalk™ into a paper-based summary sheet, including patients’ PRO scores and types of health and/or medication concerns. Both patients and pharmacists received a copy of the summary sheet and were encouraged to use it during consultation. Their consultation was then audio recorded. These audio recordings documented that during the consultation with pharmacists, patients who used RxTalk^TM were more engaged and expressed significantly more concerns compared to the control group [10].

Since the examination of real-world medication consultations through audio-recording conversations is relatively limited in pharmacy literature [6], this study offers an additional novel opportunity to explore the mechanism underlying the intervention’s impact on promoting patient engagement and expressing concerns. Guided by communication theories and using multiple data sources, a second set of analyses was done in this paper to help further our understanding of why RxTalk was effective. These analyses could inform the development and refinement of future electronic tools to collect PROs that are easy to use, meet patients’ needs, and help pharmacists provide better care.

Thus, our study aims in this paper are to (1) explore patients’ perceptions of RxTalk™ and describe their responses in the tool, (2) describe the influence of RxTalk™ on patients’ attributes and the dynamics of communication, and (3) solicit patients’ suggestions for future improvements.

2. Materials and Methods

2.1. Intervention Description

RxTalk™ was developed using Qualtrics© 2023 (Qualtrics, Provo, UT). It includes an adaptive questionnaire that tailors questions to each participant based on their responses to previous questions. RxTalk™ assesses the patient’s goals for the pharmacy visit, as well as their health and medication concerns. It also asks about the medication the patient wishes to discuss with their pharmacist, followed by two validated PRO measures related to medication adherence: the Brief Medication Questionnaire (BMQ) [11] and the Merck Adherence Estimator [12]. A third PRO measure included in RxTalk™ is the Global Health Rating, which assesses patients’ overall perception of their health [13]. The tool ends with a question that encourages patients to report any additional questions/concerns about their health conditions. A full description of the intervention is published elsewhere [10].

2.2. Study Design

This study employs a multi-method approach, utilizing data collected from RxTalk™ users in the intervention group of the pilot randomized controlled trial [10]. Multi-method studies offer numerous advantages for program evaluation, such as providing a comprehensive and richer understanding of the program under investigation, overcoming the weaknesses inherent in single-method studies, and allowing the triangulation of findings [14]. Data were collected from one community pharmacy between March and May 2023. Patients enrolled in the study were adults with at least one chronic illness that requires routine prescription medication(s).

2.3. Theoretical Framework and Constructs

The Conceptual Framework for Patient-Provider Communication (PPC) guided our data collection, analysis, and interpretation (Figure 1). According to PPC, communication is a multidimensional process that includes relationship and content and occurs in a complex environment [15]. The success of communication between patients and clinicians depends on enabling both parties to address their goals through conveying and interpreting messages. The model also emphasizes the role of participants’ attributes such as needs, beliefs, values, skills, and emotions in the communication process. Individuals’ needs include basic human needs and secondary needs (e.g. need for validation). Participants’ values encompass principles and standards that guide their behavior. Skills include participants’ ability to communicate, and beliefs are their perceptions of the world and specifics of a situation. Emotions can have either a negative or a positive valence.

Figure 1. Conceptual framework of patient-pharmacist communication [15]

Figure 1. Conceptual framework of patient-pharmacist communication [15]

2.4. Data sources and Analysis

Data used in this study were collected and analyzed using different methods and analytical techniques described in Table 1. All consultations were audio-recorded on the day of enrollment using an encrypted audio recorder placed on the counter. Two coders (BQ and BC) coded the interactions using a validated tool after establishing interrater reliability [16]. Coding focused on identifying utterances that describe active patient participation, including question-asking, concern expression, and assertive statements. Additionally, we identified the type of health and medication concerns that were shared by patients in the consultation to compare them to patients’ responses in RxTalk™.

Semi-structured interviews were conducted with patients over the phone within one week of enrollment and visit. The interviews were audiorecorded and transcribed verbatim and deidentified for later analysis by the lead researcher (BQ). Analysis was aided by qualitative analysis software (NVivo, 2020) [17]. Two coders (BQ and SM) coded the interview transcripts using a hybrid approach of inductive and deductive coding. First, the lead researcher conducted a first pass on all interviews to familiarize herself with the data. Then, a few transcripts were read word by word. Statements that described information related to areas of interest and constructs of PPC were highlighted and used to create preliminary codes and develop the initial draft of the codebook. The lead researcher then coded the remaining transcripts in addition to recoding the former transcripts using the codebook. The codes were later sorted into categories based on how they were related. The second coder analyzed the transcripts independently using the codebook, and weekly meetings were conducted to discuss any discrepancies in coding until a consensus was reached.

When available, findings related to patients’ experiences with RxTalk™ were integrated from different data sources to provide a more comprehensive and thicker description. For example, ease of use was determined by integrating researcher observations and interview questions about usability [18].

3. Results

3.1. Baseline Characteristics and RxTalk™ Data

Thirty patients used RxTalk™ as part of the RCT intervention group, and 27 (90%) completed all study activities. All study patients were white, and the majority were females (73.3%) with a mean (SD) age of 54.9 (15.8). Eleven patients had a high school diploma or less (40.7%), and the remainder had some college or higher 16 (59.3%); education data was missing for 3 patients who were lost to follow-up. Most patients were picking up refill prescriptions 21 (70%) when they enrolled in the study.

Half of the patients had hypertension, 43% had chronic pain, 26.7% had mental health conditions, and 20% had diabetes.

In RxTalk™, the patient questionnaire was designed to be adaptive and allowed users to skip questions. Based on that, patients got different screens based on their answers. It first identified patients’ medical conditions and then prompted them to select the condition with the most concerns, if any. Among the 30 patients, 22(73.3%) reported medical condition concerns: 9(40.9%) feared their condition was uncontrolled, and 7(31.8%) cited symptoms or side effects concerns. Patients who indicated that they have “No concerns about their medical condition” were asked specifically about medication issues. This stepwise approach helped capture concerns primarily tied to medications. In total, 8 (30%) patients struggled with side effects, adherence, or other medication-related problems. Finally, when asked to select a medication to complete PRO measures and discuss with the pharmacist, 70% of patients selected medications taken for more than 6 months. Four patients were excluded from the latter adherence analysis since they selected a new medication. Of the 26 remaining patients, 23.1% were nonadherent to their medications according to the BMQ. However, responses to the Merck adherence estimator show that 60% of patients were at moderate to high risk of intentional nonadherence to their medications. Only 6.6% of patients perceived their health as excellent. A full summary of patients’ responses to RxTalk™ can be found in Table 2.

3.2. Perceptions of the RxTalk™ Tool

Twenty-seven (90 %) of patients who used RxTalk™ completed the phone interviews. Patients’ responses to Likert scale usability questions and relevant quotes from probing questions are summarized in Table 3. Types of problems observed while patients used RxTalk™ are described in Table 4.

Most interviewed patients (70.4%) perceived RxTalk™ as easy to use compared to only 2 (7.4%) who perceived it as hard (Table 3). Observational data suggest that 17/30(56.7%) patients required assistance or had minor issues while using RxTalk™ (Table 4). During interviews, many patients appreciated the opportunity to answer questions electronically compared to paper and pencil surveys. Being comfortable with technology, availability of researcher support/assistance, and the simplicity of the tool made the experience easy for patients. Moreover, having to wait for a prescription to get ready facilitated the acceptance of RxTalk™. On the other hand, lack of familiarity with tablet computers, difficulty remembering the name of medications, and the need to reflect on health/medication problems before giving an answer affected patients’ perceptions of RxTalk™ usability.

In terms of future use of RxTalk™, only 11% said they were slightly or not likely to use it in the next 3 months. Many patients recognized RxTalk’s potential to facilitate communication with pharmacists and set the agenda for consultations, noting that these features would encourage them to use the tool again in the future. The small number of patients who had low intention to use RxTalk™ in the future, cited their preference for direct interaction with pharmacists or no perceived need for using RxTalk™ in the absence of health/medication concerns.

3.3. RxTalk™ and the Communication Dynamics

To explore the mechanism by which RxTalk™ influenced patients’ communication behavior of expressing more concerns to pharmacists than did the control group, we examined patients’ goals and expectations, attributes (needs, beliefs, values, skills, and emotions), and perception of the communication context as defined by the PPC framework.

3.3.1. Goals and Expectations

Only 3 patients (10%) reported in RxTalk™ that one of the goals of their current pharmacy visit was to seek consultations on their medications. Despite this, many patients expressed concerns about their health/medications during their subsequent taped encounters, as seen in our previous paper, where significantly more concerns were expressed by RxTalk™ users than by the control group. [10] This suggests that RxTalk™ not only altered patients’ goals, but it also furthered them. For example, one patient (PT47) indicated in RxTalk™ that the goal of her pharmacy visit was limited to picking up prescriptions. However, in the interview, she admitted that she had issues with her medications and was satisfied with the pharmacist's consultation and recommendations.

“He answered all my questions in a satisfactory manner and gave me a couple of suggestions to discuss with my doctor.” PT47

3.3.2. Patient Reflection and Skills to Express Concerns

Patients voiced that answering questions in RxTalk™ prompted them to reflect on their health and medication concerns, bringing these issues to the forefront of their minds. Consequently, they felt more prepared and ready to discuss them in consultations. This suggests that RxTalk™ helped equip patients with the skills and the language that they needed to express their concerns. Also, it reduced the amount of information needed to explain their medication and health-related issues.

“and I thought since you had asked the question, was there one medication that I was concerned about, that kind of then move to the forefront of my mind, that well maybe I can ask him about these things.” PT30

“it made it easier than me having to explain it all to the pharmacist after I filled out the survey.” PT24

3.3.3. Cued Pharmacist to Patient Needs

Patients perceived the summary sheet favorably, articulating that it helped pharmacists become aware of their agenda for that visit and deliver more tailored consultations. This suggests that RxTalk™ improved pharmacists' skills to identify patients’ highest concerns. This has the potential to streamline consultations and reduce the workload for pharmacists during busy hours.

“I think it prepares them when they call you up to pick up your medicine to go over the one thing or two things that you were specific in wanting to know” PT3

Interviewer: “So do you feel that there are certain situations that make you more likely to use it in the future versus other situations?”

Patient: “When it does get crowded, plus, sometimes, even if it's not crowded, they do get a lot of calls. There's a lot of times when someone can't be there.” PT43

3.3.4. Needs

Using RxTalk™ fulfilled patients’ need to connect and feel cared for. They appreciated the opportunity to “talk to the pharmacist” after using RxTalk™, which is not commonly done during refill medication pickup.

“That we got to sit there, talk face to face. Usually, I just go in there and get my medicine and come right back out.” PT26

In addition to relational needs, the personalized consultation that patients received after using RxTalk™ addressed their informational needs and helped them get answers to questions that they never thought to ask any of their other healthcare providers.

“It answered questions that I had for 30 years and just never bothered to ask” PT39

3.3.5. Preferences and Values

Patients’ interviews indicate that RxTalk™ lowered the threshold for sharing concerns and validated the appropriateness of discussing any medication-related issue patients might be experiencing, even if they were minor.

“I think if it would have been a really strong concern, I would have called and talked to them or talked to him at a time when he was, you know, giving me, when I was buying other medicines.” PT30

In the same vein, taped encounters demonstrate that issues that are sensitive for patients to raise, such as mental health, were discussed openly in 6 (20%) of the encounters. The tapes also indicate that patients selected and discussed medications picked up from other pharmacies in 3 (10%) of the taped encounters, as the pharmacist was heard saying the medication was not found in the patients’ profiles. This suggests that the RxTalk™ helped patients overcome their values and beliefs of only discussing medications that are picked up from that pharmacy.

3.3.6. Emotions

A few patients reported that engaging in direct conversations with pharmacists could induce anxiety, particularly if they perceived the pharmacists as busy and not open to interruptions during their work. However, completing the questions in RxTalk™ contributed to alleviating these patients' concerns and fostered their confidence in voicing their concerns and questions through the tablet.

“It's easier to write the answers sometimes on the computer or the tablet because you can be nervous sometimes without asking the pharmacist, especially if they're busy.” PT5

3.3.7. Environmental/ Contextual Factors

Most of the patients, 19 (70.4%), reported that they had a positive experience completing the RxTalk™ questions in the pharmacy's waiting room. The remaining patients, 8 (29.6%), had a negative perception of the limited space and inconvenience in the pharmacy.

“It was probably a pretty good way to do it while I was waiting in order just to fill it out.”PT53

Since the pharmacy had limited privacy and was located in a close-knit community, patients appreciated the ability to type in their concerns and sensitive information without being heard by others. The privacy feature was especially useful for patients employed at the hospital when the pharmacy was crowded and there was a high risk of losing privacy.

“I guess the thing, the privacy, part of it. That I'm able to ask that question, and you know it would have been fine if he was able to respond on it that way”.PT30

3.4. Suggestions for Improvement

3.4.1. RxTalk™ Features

Patients gave a few suggestions about improving the design and content of RxTalk™. Comments included adding more instructions, including a text box under health/medication concerns, to provide more contextual information. Additionally, patients suggested integrating a risk assessment system within RxTalk™, which flags patients who require prompt attention by pharmacists and filters out those with no issues or real concerns.

3.4.2. Setting for Using RxTalk™

For future use, only 8 patients (29.6%) suggested using RxTalk™ in the same way it was used in the study, in the pharmacy waiting area. Most patients, 14 (51.9%), preferred to use it remotely at home using a link sent to their phones or personal computers. Other suggestions included completing the questions in the pharmacy away from traffic, inside patients’ cars in the parking lot, ahead of medication review appointments, or securing the tablet on a kiosk in the pharmacy for better convenience and privacy.

3.4.3. Feedback from Pharmacists

Seventeen patients (63%) expressed their appreciation for receiving feedback through face-to-face interaction with pharmacists to allow bidirectional communication. Some patients were also open to other ways of asynchronous communication for receiving pharmacist feedback, such as text messages, email, pharmacy app, or RxTalk™ itself. One patient suggested having a written document with the pharmacist’s recommendation following the consultation. Lastly, a few patients expressed interest in receiving a phone call from their pharmacist to discuss issues that were recalled later.

4. Discussion

4.1. Discussion

This study is among the first theoretically driven, in-depth evaluations of the experiences of patients with chronic medical conditions with an electronic PRO tool in a community pharmacy setting. One of the strengths of this study is the utilization of multiple data sources to explore how an interaction with an electronic pre-consultation tool can shape patients’ communication with pharmacists. Having RxTalk™ collect PRO data about patients was perceived positively as the tool was quick and straightforward to use, and it gave pharmacists insights into their questions and concerns. The prompt integration of patients’ responses in RxTalk™ into the consultation helped patients see the value of RxTalk™ and how their data was being used by pharmacists, which improved its acceptability. The finding that most patients found RxTalk™ easy and useful becomes even more significant considering that in this rural setting, 40% of the study sample had high school education or less, and many patients expressed a lack of comfort with technology. This suggests that using simple tools, such as survey software loaded onto a touch screen device, has the potential to successfully monitor medication use in rural underserved areas to augment limited staffing resources.

Demonstrating that an intervention is effective is not adequate without exploring how it works, why it works, and under which conditions [10]. The Conceptual Framework for Patient-Provider Communication constructs proved helpful to explore how RxTalk™ influenced patients’ interaction with pharmacists. It helped explain how the PRO assessment tool could influence a complex behavior, such as patient communication about their concerns [19]. Having the written summary for both patient and provider was a key element to cue both the patient and pharmacist during their encounter that a dialogue was expected about patient concerns. Additionally, having RxTalk™ ask a brief set of questions about concerns and behaviors helped patients reflect on and identify their concerns. It gave them language to share these concerns with the pharmacist and validated the appropriateness of discussing long-standing issues and problems not related to the visit. Pharmacists’ perceptions of RxTalk™ and how it influenced and informed their interactions with patients, compared to standard consultations also was positive and will be described in detail in a different paper.

Most patients in this study identified concerns in RxTalk™ with medications they had taken for more than 6 months. This underscores the importance of shifting the focus from simply counseling on new prescriptions to including refill prescriptions. Tools such as RxTalk™ could identify which patients have concerns about refill medications. As adherence decreases over time [20] and adverse effects are prevalent [21], RxTalk™ can help uncover issues through medication use assessment and create more interaction opportunities between patients and pharmacists. This can potentially improve health outcomes for patients with chronic medical conditions. Patients reporting medications refilled from other pharmacy sites in RxTalk™, such as chain pharmacies and mail orders, was an unexpected finding. This highlights that PRO tools can reduce fragmentation in care and contribute to medication reconciliation, especially when implemented in a pharmacy site with strong patient loyalty. This finding will be considered when redesigning RxTalk™ in future studies.

As the management of privacy can be challenging in the busy pharmacy environment [22], RxTalk™ was deemed valuable when patients had concerns about diseases with sensitive connotations like mental health issues and chronic pain, which were discussed in one-third of the encounters. Given the low frequency of the discussions of these conditions in pharmacy consultations, these findings suggest that RxTalk™ helped normalize the dialogue about sensitive conditions and provided a safer, private space for sharing the context of these problems [23,24].

The researcher’s assistance was essential for the successful implementation of RxTalk™. While comprehension issues can be resolved by improving the instructions in future iterations of RxTalk™, technical issues need special consideration. Assigning one pharmacy personnel as a technical support person would encourage patients’ adoption and ensure a seamless experience, especially for older adults and those with limited experience with technology. This aligns with the recommendations from another similar study in clinics, which showed that individual assistance facilitated the uptake and adoption of digital tools [25,26].

This study has several limitations. The study was conducted in a rural setting with a relatively small sample, which limits the generalizability of patients’ experience with RxTalk™ to urban and metropolitan settings. Also, since sampling was not random, it is possible that patients who joined the study were more likely to be receptive to using technology compared to those who didn’t. However, many patients expressed a lack of comfort with technology at the start of using RxTalk™, which reduces the possibility of this risk. Lastly, future studies should invite patients in the control group to use RxTalk™ as a wait list control to make an in-depth comparison between the two groups and rule out any possible confounders.

4.2. Practice Implications

Pharmacies can adopt several strategies to facilitate the integration of PRO tools in their settings and provide tailored consultation to their patients. The reluctance of some patients to use the tool can be addressed by sending pre-visit text messages to patients to inform them about the PRO service, which can alter their expectations of the visit and its duration. The pharmacy team should also introduce the tool using a carefully crafted message emphasizing the importance of monitoring medication use, efficacy, and side effects [27]. For better efficiency, the pharmacy team can utilize a risk-based approach and target at-risk populations such as older adults, patients with polypharmacy or multiple comorbidities, and those with refill gaps in the pharmacy dispensing system [28]. Patients who are typically reserved or hesitant in their communication can also benefit from using such tools [29].

Patients’ preference to complete the PRO assessment remotely before the pharmacy visit can be further explored in areas with better internet connectivity to identify the opportunities, challenges, and overall patient experiences. Studies examining the integration of PRO with patient portals (MyChart; Epic Systems) have demonstrated that patients completing PRO assessments in the comfort of their homes was feasible, well accepted, and contributed to higher contextualization of care [26,30]. Additionally, pharmacies can capitalize on patients’ comfort with existing infrastructure, such as their pharmacy app for patient targeting and PRO collection.

4.3. Conclusion

Using RxTalk™ was perceived positively by patients as it prepared them for the consultation and gave pharmacists insights into their concerns. To expand evidence on the feasibility and acceptability of RxTalk™, future research needs to explore patient experiences in other pharmacy settings, urban locations and include different types of encounters, such as drive-thru visits and videoconferencing consultations.