Proceedings of the 35th Hawaii International Conference on System Sciences - 2002
Building common ground for communication between patients and community pharmacists with an internet medicine cabinet Jean-Pierre Calabretto1,2, Jim Warren3*, Kathy Darzanos3, Benjamin Fry3 1 Pharmacy Department, Adelaide Women’s and Children’s Hospital, 2 School of Pharmaceutical, Molecular and Biomedical Sciences, University of South Australia 3 Advanced Computing Research Centre, University of South Australia Email:
[email protected]
Abstract Increased levels of patient satisfaction and compliance are found when they assertively participate in clinical conversations. The Internet may be able to aid communication between the patient and the community pharmacist, particularly if the patient is in control of their record. We propose an Internet Medicine Cabinet that affords this aid by providing “common ground” for conversations. This should provide concrete objects for patient-pharmacist communication and allow online storage of current medication details, recording of problems / issues related to medication, and online education facilities. These first two functions have been implemented in a prototype service called Winston. In collaboration with the Adelaide Women's and Children's Hospital, oncology and asthma patients are being enrolled in a trial wherein they maintain their own online records to share with their community pharmacists. We report the rationale, architecture, usability testing results and future plans for Winston.
1. Introduction 1.1. Internet-enabled partnerships The Internet provides opportunity to build partnerships between patients and health providers [1]. Increased levels of patient satisfaction and compliance are found when patients more assertively participate in clinical conversations [2]. Establishing partnerships with patients is also seen as vital for the future community pharmacist’s role [3]. Although not as thoroughly studied as doctorpatient communication problems, pharmacists and patients have different perceptions of therapies that may confound communication [4]. Patient satisfaction with pharmacists has been shown to correlate with social interaction, although not necessarily with the level of care [5]. However, pharmaceutical care has been shown to
increase patient awareness of medication side effects [6]. Community pharmacists provide a useful advisory role for minor ailments, thus avoiding unnecessary visits to general practitioners; and community pharmacists can also act as referrers in cases that merit General Practitioner (GP) consultation [7]. The key to greater consumer participation in health care decision-making is better information [8]. Informed consumers would be in a better position to approach the consumer-provider relationship as more of a partnership of shared decisionmaking [9]. While some consumers may want to continue to leave all decisions to the provider, those who want to take a more active role in their health can only do so effectively if they are in a position to make informed decisions [8]. For that matter, there is serious doubt that providers themselves are in possession of all information at the point of care that they would want in order to do best for their patients [8]. The proliferation of health information and self-help communication facilities now commonly accessible on the Internet has been hailed as a transformation in health care [10]; however, it has also raised concerns about the quality of on-line information [11]. The Internet need not take consumers away from traditional sources of quality information; for instance, doctor-patient communication by e-mail has technical benefits in facilitating clarification of previous advice and including links to Internet sources of further information [12].
1.2. Complementary medicines
and
over-the-counter
Information that is often lacking at the point of care is that relating to Complementary Medicines (CM) or Overthe Counter (OTC) medications [13]. The popularity of CM is increasing based on the perception of being ‘safer’ than conventional medicines [14-15]. Within one year in Australia, almost half of a representative sample of consumers had used at least one non-medical complementary remedy and at least one in five had
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attended a non-medically trained complementary therapist. Moreover, a study by Pirotta et al [16] found that “doctors underestimate their consumers’ use of these therapies, which may contribute to compliance and medication interaction problems.” A recent survey of complementary therapies used by the Oncology and Cystic Fibrosis (CF) patient groups at the WCH found that 56% of CF patients and 63% of oncology patients had used, or are currently using, at least one form of complementary product or therapy in the management of their medical condition. Amongst the CF patients, 33% had used five or more products and therapies. There was a more even distribution in the number of products and therapies used by the oncology patient group [17] CM may interact with pharmaceutical drugs (and other CM) to decrease or increase therapeutic effects or cause toxicity [18]. Adverse reactions to CM are likely to be under-reported as there is no encouragement to do so by the Adverse Drug Reactions Advisory Committee (ADRAC). The poor documentation of CM in patient records and the public perception that they are safe, biases against the association of CM and adverse effects [15]. Self-medication with OTC medicines has long been a feature of the lay health system and is becoming an increasing area as governments see this as a means of shifting some of the cost of health care onto consumers [19]. This trend towards increased care however, provides increasing empowerment of patients with many benefits, although greater collaboration between doctors and pharmacists will be critical [19]. Drug interactions between prescribed and OTC medications are well described, with the elderly and paediatric populations considered to be at highest risk [20]. It has been estimated that up to 53% of Australians use OTC pain relievers in any two week period, and as many as 66% of British children use a non-prescription drug over a 4 week period [20]. Patients appear reluctant to discuss their selfmedication practices with their general practitioner, and currently prefer pharmacists as a more acceptable source of advice [13]. Knowledge of OTC medications is essential to guard against drug interactions [13]. Even with the use of conventional medicines, the cause of adverse effects is not often immediate, and this is especially true for substances used ‘outside’ of the conventional health setting, as there is no adequate system of reporting adverse events that may be associated with these products [13, 14, 15]. A uniform approach to the recording of personal health information in relation to complementary health care would be desirable but the role of the electronic health record in this is uncertain at present [8].
to establish Health Information Networks (HINs) that integrate health data for cheaper and better quality health care [21]. A popular proposal has been to hold patient information on a smart card [22]. A study of patient-held records (PHR) in South Australia in the context of General Practice was inconclusive on health outcomes, but recommended further implementation and evaluation PHR were well received and increased responsibility sharing [23]. Less data is available on how PHR affect the pharmacist-patient relationship. However, with the rise of the Internet, the favoured solution is moving to the use of the smart card as a key to encrypted Internet access of patient data rather than as the actual repository [24, 25]. Many developed countries are considering or have already implemented a national HIN based on an access card (e.g., France [24]). These HINs integrate records of hospitals and community-based providers, generally through health insurance, with minimal consumer consent or knowledge. Such a tracking system, through the Health Insurance Commission (HIC), has been announced for Australia [26]. In most HINs, the provision of a patient portal to the data (if it exists at all) is a minor feature. The recent report, A Health Information Network for Australia, in outlining an Australian plan for a HIN, proposes improved delivery of healthcare, better quality of healthcare, consumer safety, privacy and dignity, in part by empowering consumers to take a greater responsibility for their own health care, to be better informed about the choices available to them and better decision making which is shared by consumers and health providers at the point of care. This rests on the better exchange and sharing of information [8]. We believe that there is an under-exploited gulf between provider-centred HINs and conventional Web sites that act as information hubs for consumers (e.g., http://www.drkoop.com/ or the Australian government’s http://www.healthinsite.gov.au/). We particularly note this gulf with respect to the relationship of patient to community pharmacist in light of the medication and partnership issues we have cited above (which give reason to hypothesize that stimulation of substantive patientpharmacist communication may lead to consumer health benefits). In the next two sections, we present our concept and trial details of an Internet Medicine Cabinet that provides common ground in support of patientpharmacist communication. The architecture of Winston, our Internet Medicine Cabinet implementation, is described in section 4. Section 5 summarises usability testing results on Winston. We conclude with a discussion of our future plans.
1.3. Health information networks
2. Internet medicine cabinet concept
Looking to how Information Technology (IT) may aid health communication issues, there are numerous efforts
An important consideration in communication between a patient and the community pharmacist is the patient
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feeling comfortable and in control of the process of divulging information to the pharmacist. Comfort can be achieved by the patient having full knowledge and control of the Internet record, ideally by having a convenient portal for full access to the record. Control is achieved by being able to author items into the record. This is further enhanced by knowing the record is secure and by having a physical token of access, such as a smartcard, that literally and symbolically represents the right of access to the information. The net effect is the patient’s conceptual ownership of the record. An Internet Medicine Cabinet is proposed to fulfil this communication enhancement role, by providing patient-centred, and largely patientcontrolled, common ground for relevant patientpharmacist discussions In general, common ground is the understanding (knowledge, beliefs, suppositions) accumulated during the course of joint actions, which the parties involved believe that they share [27]. Clark [28] argues that to understand how joint actions proceed we must take common ground to consist of three parts: 1. Initial common ground – what the participants share at the inception of the activity; 2. What they understand the shared state to be; 3. The public events (history) of the activity so far. The Internet Medicine Cabinet can afford common ground for patient-pharmacist communication by providing a persistent, mutually accessible store of relevant objects of discussion. That is, the Internet Medicine Cabinet is to provide objects in the sense of Shneiderman’s [29] object-action interface model of interactive system design. Objects, in this sense, are realworld objects that are important to the task at hand. The objects are metaphorically represented on the computer (made visible, for instance as icons or lists) and allow actions to be applied by the user (e.g., via clicking with the mouse). Such objects do not necessarily correspond one-to-one with software objects in the sense of objectoriented programming. We see two classes of objects as particularly natural and relevant to include in the Internet Medicine Cabinet, that appear efficacious in the common ground affording qualities: 1. Medications – obviously, the principal topic of conversation. The list of current medications should be complete, including CM and OTC medications, as well as those acquired through the hospital system, in addition to those traditionally dispensed by the community pharmacist. Past medications are also relevant, particularly with respect to reason for cessation. 2. Discussion “Issues” – issues (such as unpleasant symptoms, or fears). These may be directly related to a medication or not (quite often the real answer would not be known, at least initially). Their management as a named discussion thread makes them concrete and provides the history of the discussion. Providing
discussion as a central system entity is in keeping with Coiera’s conclusion that current IT solutions in health are overly focused on the processing of highly structured information at the expense of facilitating less-structured human-human communication [30]. Less central entities with common ground affordance efficacy include allergies, diagnoses, hospitalisations and a list of doctors. On-line education for patients would also be valuable for building common ground, in the sense of expanding shared understanding of the healthcare process and shared vocabulary; however, such facilities are outside of our current scope of implementation. The understanding of shared state expressed by Clark [28] is explained within the Internet Medicine Cabinet through the patient’s conceptual ownership of the record. As described above, the participants are clear on ownership and access issues that surround the record, such as the use of a smartcard. Similarly, Clark’s notion of public events of the activity is expressed by the historical trail of entries relating to medication entries and issues raised by the patient. A key issue to the project from the perspective of patient participation is trust in the information-sharing relationship. Research by Novak et al [31] reveals that consumers have a lack of trust arising from perceived lack of control over the access others have to their personal information during the online interaction, with 87% of Web users thinking they should have "complete control" over demographic information captured by Web sites. The primary barriers to consumers providing demographic data to Web sites relate to trust and the nature of the exchange relationship, with consumers wanting full disclosure on how their information will be used, and informed consent. Recognizing consumers’ rights to data ownership on the Internet is an important first step to establishment of trust. Similarly, Buckovich et al [32] in defining a number of guiding principles for privacy, confidentiality and the security of health information, also emphasise informed consent and individuals’ control over how their health information is stored and disclosed. These underlying principles form the basis of trust within the Winston trial.
3. Internet medicine cabinet trial We have implemented an Internet Medicine Cabinet, called Winston, with Medications and Discussion Issues as the central entities. It is implemented as a Web site with secure access to the Medicine Cabinets of particular patients controlled by smart cards. Medicine Cabinet contents are meant to be shared (in viewing and updating) by the patient and their community pharmacist, but with explicit patient consent on every access by the community pharmacist. Although this adds inconvenience for the pharmacist, this is important in the establishment of trust.
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The security model is that all users must scan their individually issued card for access and provide a PIN (person identification number), much as for a bank machine. All user activity is comprehensively logged (to support analysis of use and communication behaviour, but also to support detection of inappropriate access and to emphasise accountability to pharmacist users). For community pharmacist users, once logged in, they must then identify the username and PIN of a particular patient to open that patient’s Medicine Cabinet. In future we would like to go to a two-card system where the patient’s smart card (as well as the pharmacist’s) is physically required for pharmacist access, but this is currently impractical for the scenario of patient enquiries made over the telephone. We are organising a trial of Winston in collaboration with the Adelaide Women’s and Children’s Hospital (WCH) with the intent to enrol 30 oncology and / or asthma patients to maintain their own online records to share with their community pharmacists for a period of six months. These patient groups are chosen for their high medication complexity, dedication (particularly with respect to oncology), the long-term nature of their illnesses, and tendency to use CMs [14]. We are enrolling only patients who are familiar with Web browsing and have a home computer and modem. While this may not be entirely equitable, we are interested in establishing the usage of the Medicine Cabinet for those most motivated and able to use it. If positive effects are observed in this cohort, then there is some basis for exploring the outreach of the technology to patients on the other side of the Internet Divide. Due to the fact that most of our potential patients are young children, the term “patient” in fact refers to the patient’s family, with parents being the most common users with the exception of some teenage patients. For our trial there is a third class of user, the hospital pharmacist (in practice, the first author). The hospital pharmacist also uses a smart card for access, but unlike other users, may perform functions without direct patient consent. Routine functions of this role are: (a) updates of patient records upon discharge from WCH and (b) viewing of patient records to support telephone enquiries from community pharmacists who are currently logged onto a patient’s Medicine Cabinet. The hospital pharmacist is in a sense the caretaker (and resident “expert”) of the Winston virtual community (at least of the particular community created by the first field trial). The hospital pharmacist is supported by a system administrator user class that manages user accounts. Patients and community pharmacists opt into the Winston trial with informed consent of the access policy. Moreover, patients agree to attempt to keep the medication record in the Medicine Cabinet as accurate as possible. Community pharmacists are invited to the trial to suit the geographic needs of the enrolled patients.
Community pharmacist users agree to log into the patient’s Medicine Cabinet all medications that they dispense to that patient. Additionally, community pharmacists agree to attempt to address all discussion issues logged by the patient, and to seek the advise of the hospital pharmacist where appropriate (e.g., for interpretation of hospital discharge medications). They may, of course, choose to contact the patient’s General Practitioner (GP), although this person is not part of the present Winston network. The trial is, of course, exploratory in nature – lacking a random selection and a control group. Comparison of pre- and post-questionnaires, along with analysis of system usage logs will form the foundation of assessment, both qualitative and quantitative. Questionnaires will inform as to whether Winston did provide common ground for patients and community pharmacists. In particular, facilitation of, and satisfaction with interaction, increased patient involvement with, and confidence in managing medication. Questionnaires were tested on a small patient cohort to improve readability and clarity. Notably, we will also be looking for medically relevant “discoveries” by pharmacists (e.g., drug-CM interactions) made in conjunction with viewing the Medicine Cabinet contents. These observations will set expectations to form the basis of targeted studies of effects from the Internet Medicine Cabinet approach. A further interesting question is the motivation of the pharmacist to use the system. The use of the Internet Medicine Cabinet certainly may be more time consuming, and this issue has been raised in early discussions with potential pharmacist subjects with busy practices. However, pharmacists are interested in demonstrating that they have a role in influencing patient outcomes [33], and there is increasing evidence of initiatives in which doctors and pharmacists are forging links to improve patients’ use of medicines [13]. One could postulate that part of the motivation could be the ability to sell more medicines in response to requests for information, but research shows that this is not always the case [19]. The trial will give us an insight into pharmacists’ motivation and how Winston is perceived in terms of demands and benefits.
4. Winston architecture The Winston Web service provides the portal for participants with account-based secure storage of medication history and patient questions/issues, representing the ‘initial common ground’ entities [28]. The conceptual architecture separates business objects, workflow and webflow design [34]. In practice for our system the most important divide is between the business object layer and the combination of workflow and webflow that amounts to the user interface. Only business objects “know” how to access the electronic medical record (EMR) database. Completely insulating
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the interface code from database issues provides independence, flexibility and reduced complexity for both the business object and interface implementations. This is particularly important to support our iterative interface design process (see section 5). It is critical that changes to the “look and feel” of the system are as easy as possible to encourage us to be responsive to user feedback regarding usability as usability issues should not overshadow the main aims of the common ground principles, which amount to confident and unimpaired sharing of information. The business objects are in fact relatively stable as the storage needs and processing methods of drugs, patients, and discussion threads were easily predicted and vary little even if presented in very different looking user interfaces. Access is over the Internet with the Microsoft Internet Explorer 5 (IE5) browser (we support a single browser type for ease of script development since we require an onsite setup of each accessing system anyway to install the card reader hardware). The Web server invokes a Secure Socket Layer (SSL) encrypted session and demands a client certificate. The client certificate, purpose-issued for the Winston trial, is read from the smartcard, identifying the user’s identify and role (patient, community pharmacist, hospital pharmacist or system administrator). A serial-port based smartcard reader is installed on each machine able to access the service. A password completes the logon for patients. Pharmacists must also supply username (physically labelled on the smartcard) and password to logon to a particular patient’s cabinet. The implementation architecture for the Web server uses Microsoft Internet Information Server (IIS) with Active Server Pages (ASP) to implement the interface. The ASP code generates HTML with some IE5dependent Javascript to generate the interface browsed by the client/user. We avoid the use of applets or client-side ActiveX and stick to conventional HTML-based interaction as far as possible to leverage user experience of other Web sites. The ASP addresses the EMR exclusively through a collection of business object classes encapsulated in an ActiveX dynamic link library (DLL). The object classes implement the interface-independent behaviours such as allowing a drug to return its generic and product name, or an issue discussion to add a new response message. Notably, we implement an object class “pat-drug” for the relationship of a patient using a drug. Although this “object” is really the relationship of two other objects, it is so central to the Internet Medicine Cabinet as to be natural as its own class (in fact, “patdrug” and Issue correspond to the chief user interface objects for providing common ground for patientpharmacist communication). Figure 1 illustrates the Winston system architecture.
Client certificates
PC
PC
PC SSL connection
Web Server (Microsoft IIS) Winston.asp
Clients with IE5 browsers and smartcards with readers Server certificate
ActiveX
Winston. dll Patient “pat-drug” Drug ... Issue ODBC
Electronic Medical Record
“Business object” classes
(Microsoft Access)
Figure 1. “Winston” Internet Medicine Cabinet system architecture. The interface design emphasises the central metaphor of the Medicine Cabinet – that is, the patient’s set of current medications. Logon is immediately succeeded by the Medicine Cabinet main screen (see figure 2). Functionally, the medicine cabinet screen is a set of hyperlinks to details and further actions on these medications, such as stopping the medication or changing dose. The design de-emphasises “browsing” per se – we open the Medicine Cabinet in a window without the standard navigation controls or Web address display. The user isn’t wandering about in an arbitrary hyperdocument, but rather is operating an information system with a narrow (but important) set of functions. This provides a clearly bounded forum for patient-pharmacist communication. The top navigation bar represents the major user objects (common ground for patient-pharmacist conversation) in left-to-right order of relevance to the type of conversations we expect (i.e., medications and issues foremost). Applicable actions on the current user object appear on the sidebar menu. The design is no-nonsense and lacking in flash – users are focused, for example, on their child’s treatment. Graphical flags help to focus attention, especially for benefit of the community pharmacist. For instance, in figure 2 the patient has an issue (flagged by a red “!”) with their Ibuprofen, an issue not associated with a particular drug that has not received a response (red “!” in navigation bar), and an outpatient medication from the WCH.
5. Useability testing Design of a highly approachable user interface that achieves accurate user performance with minimal training is obviously a central requirement for success of the
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Participants were six WCH patients, three community pharmacists and two WCH staff with no prior experience of the Winston prototype (excepting one patient that had commented on an earlier set of screen designs). The “patients” were in fact four parents and two cancer sufferers (early and late teens). Participant gender was split nearly 50/50. Each usability test participant underwent a one-on-one session with a test administrator. The session began with a 15-minute orientation and system tour (similar in depth to our enrolment procedure for trial users). This was followed by the user being set a battery of tasks to perform without assistance, including addition of a new Figure 2. The main “medicine cabinet” screen of Winston. medication of their choosing (for patients, one that they are taking) to Internet Medicine Cabinet in practice. In following the the Medicine Cabinet, as well as creation of a discussion common ground principle, clearly the artefact that issue. The task required on the order of 30-45 minutes supports this, namely Winston, should not in itself be a (no explicit time pressure was applied). Problems and confounding influence. It is therefore important that the comments were noted. interface reflects desirable user characteristics that will Table 1 summarises the major usability findings. The best support communication and information sharing. We strengths identified from usability testing are encouraging have followed the user interface design principles of with respect to the capability of Winston to build common Weinschenk et al [35] emphasising iterative feedback of a ground for patient-pharmacist communication. Having spectrum of technical, managerial and user the complete medication record available establishes the representatives in analysis and design of the interface. initial common ground and shared state for conversation. Difficulties associated with the early recruitment of The medication notes provide a chronology of events for patients and community pharmacists resulted in less-thandiscussion. Moreover, the perceived ease of navigation is ideal advancement of the prototyping process in terms of encouraging as it indicates that users will be able to forget user feedback, however, user surrogates (e.g., people the tool and concentrate of relevant topics related to the “like” the potential patients and community pharmacists), data represented in the Winston interface. The usability including the authors, maintained an atmosphere of open problems are being addressed through a variety of and iterative review as the design consolidated. Field approaches, including screen layout adjustment, trips for demonstration at WCH were also organised and adjustment of emphasis for our orientation training, and provided valuable corrective and supportive feedback content of on-line help and tool tips. Most worrying is from staff and patients. the feature of adding “characteristics” to a discussion In light of the vulnerability of the project to usability issue. These are essentially keywords or classifications issues, and deficiencies in early user involvement, we for the issue, such as dizziness, nausea, headache, etc. opted for administration of “low interaction” usability The fact that “Dizziness” may be the subject of a tests [35] across a range of users (i.e., usability tests discussion and also a characteristic of that discussion was where the subjects are allowed to struggle and make observed to be confusing. This confusion is difficult to errors without intervention from the test administrator). fix entirely in the user interface in that an appreciation of The advantage of ‘low interaction’ testing is that, as naïve the value of classification per se is essential to the feature users of a system, the subjects provide uninfluenced and being intuitive. We have reorganised the Add Issue therefore very useful information on usability. This screen to integrate better with setting of characteristics contrasts to ‘high-interaction’ testing where the test and are retrying this with a selection of “pioneer” users in administrator intervenes more; the danger here is that test advance of the full trial. sessions may end up as demonstrations and become design reviews rather than usability tests [35].
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Table 1. Summary of Winston usability test findings. Strengths Peace of mind in having complete medication record available Medication notes will help in remembering reactions to drugs Easy to understand and get around Problems Difficulty
Action Taken
Patients: Confidentiality – might not want the pharmacist to know you’re on certain medications
Will monitor extent of problem is trial
Pharmacists: Need access to the record all the time to be able to address ‘issues’, not just when the patient comes into the pharmacy
Have allowed possibility of patient reading username and PIN to pharmacist over phone – pharmacist’s smartcard used for logon
Need to be able to delete a mistakenly added medication
Added Delete Medication function (see text)
Difficulty finding Lookup Medication function (majority of participants)
Moved Lookup function to left, gave colour highlighting – need to confirm adequacy of fix
What does “set characteristics” on an Issue/Discussion mean?
Better integration of characteristic setting with issues/discussion creation
Can easily prematurely exit Add Medication screen (esc, Enter, clicking on navigation buttons)
Always prompt to clarify that Medication data will be entered (or discarded, as the case may be)
Usability testing also brought about discussion of issues touching on core ethical issues around a service such as an Internet Medicine Cabinet. The participants accepted the security of the system from outside access, but at least one participant was concerned about sharing full medication details with the community pharmacist and on the potential of falsifying medication records. Moreover, pharmacists (although, interestingly, not patients) indicated that phone enquiries must be supported, which stretches the effectiveness of our security solution. Also, we would rather not have a Delete Medication function, but for practical reasons of
user inexperience or confusion it seems that there must be one (it will still be present in the EMR, but not visible to end users). Conceptually, one can Stop Taking a medication, but it’s always part of the medication history; a Delete function is just part of the syntax of system interaction – this distinction is likely to create difficulties. Overall, the usability test findings are sufficiently positive to proceed with the field trial after minor revision. Both patients and pharmacists are highly enthusiastic about the advantages and peace-of-mind the system offers, with this outweighing concerns and use problems. We can be relatively confident therefore that interface issues will not impact on the common ground notion.
6. Discussion We have implemented and conducted usability tests of a Web-based information service for patients that allows them to maintain an Internet-based Medicine Cabinet. The Internet Medicine Cabinet service, “Winston,” is designed to provide common ground for productive conversations between patients and their community pharmacists who also view the Medicine Cabinet contents. Our next step is a field trial with 30 oncology and asthma outpatients of the WCH and associated community pharmacists. Maximal success of the system for stimulating clinically relevant conversation is obviously bounded by the degree of trust patients place in their community pharmacists. Known population levels of use of CMs will give us some indication of how forthright patients are being in field trial use of Winston. The project is significant in contributing evidence to the rising debate surrounding HIN initiatives at a time when Australia is on entering into a variety of provider and government centred HIN activities. Moreover, the project will address the imbalance toward studies that investigate the role of the doctor (or nurse) as compared to that of the pharmacist. While we intend to expand the network to other health service providers (e.g., GPs) if it is successful, our foremost goal is better understanding of the potential of the community pharmacist to offer expanded benefits to patients. We are also interested in the knowledge and education features that could parallel and complement the datacentred functionality implemented in Winston. For instance, the Winston EMR can provide a user model (profile) to enhance Internet search capabilities. The profile can also be related to best-practice guidelines for treatment of the patient’s condition. At present Winston does not provide even conventional knowledge-based features, such as drug interaction checking. We are currently investigating an agent architecture to provide search, guideline and interaction-checking support for patients and pharmacists on the foundation of Winston.
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7. Acknowledgement Thanks are owed to our corporate supporters, ASC Computer Software, Motorola and Chariot Internet, as well as to our respective employing institutions. Special thanks are extended to the Women’s and Children’s Hospital patients, family of patients, and staff – and the several community pharmacists – who have provided support for our analysis and usability study activities.
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