Expert interviews.

The research team (FB, M-SB, TSD, JE, A-AK, KM, JP, LR, MvdA, KV) developed nine stakeholder-specific, semi-structured interview guides based on the “Manual for Conducting Qualitative Research” by Helfferich [51], and covering collecting, checking, sorting and subsuming research questions. This yielded interview guides for HCPs focused on relevant stakeholders and their tasks, challenges, ideas for solutions and best practice examples regarding medication management in transitions of care. Clinical information scientists were asked to provide their view on the current situation concerning the exchange of information between care settings including challenges and ideas for solutions. The interview guides for patients and caregivers concentrated on their most recent hospital admission including their challenges and ideas for solutions. Patients were interviewed as experts on their own behalf and based on their own experiences. Examples of an interview guide for each inpatient and outpatient HCP group and patient stakeholder group can be found in S1–S3 Files.

Prior to conducting the interviews, one interview guide (GP guide) serving as an example was discussed in depth in an interdisciplinary qualitative research group at the Institute of General Practice in Frankfurt. Five researchers (M-SB, TSD, A-AK, LR, KV) then pre-tested all interview guides in pilot interviews and adapted them accordingly. Between October 2020 and January 2021, the same researchers conducted the individual expert interviews by telephone, using the web-hosted service GoToMeeting [52]. Four of these researchers were experienced in conducting qualitative interviews, and the fifth was carefully instructed by the experienced team members. The interviews were audio-recorded with the consent of participants, and transcribed verbatim by a professional transcription office and experienced staff of the Department of General Practice / Medical Clinic III, Faculty of Medicine Carl Gustav Carus, TU Dresden, Germany and the Institute of General Practice, Goethe-University Frankfurt am Main, Germany. To ensure data protection, transcripts were anonymized and pseudonyms were created for the presentation of results (“GP” for general practitioner, “HCA” for healthcare assistant, “ACN” for ambulatory care nurse, “IP” for inpatient physician, “IN” for inpatient nurse, “HP” for hospital pharmacist, “CG” for caregiver and “CIS” for clinical information scientist, plus an individual number, and “f” for female or “m” for male). Transcripts were not returned to participants for comments and/or corrections. Field notes were taken after the interviews.

Questionnaires.

Interview participants received stakeholder-specific questionnaires via e-mail for purposes of collecting sociodemographic and clinical data such as age, sex, working experience and environment. The patient questionnaire included variables on sociodemographic and health-related data. Informal caregivers were also asked about the support they provided to their relative in daily medical care.

Topic 1: Stakeholders and tasks.

Participants identified key stakeholders involved in transitions of care. In the following, we describe medication-related tasks of stakeholders during transitions of care. These might differ depending on the patients’ individual journey and whether the hospital admission was planned or unplanned.

Hospital referral. GPs reported that for planned hospitalizations they check the medication plan for currentness and completeness, and modify it as needed:

“Is [the medication plan] up to date? […] Has the dosage changed? Occasionally some specialist findings have been added to it. […] And whether something else needs to be included for self-medication.” (GP06f)

The updated medication plan must be printed and handed over to patients who are supposed to take it to the hospital. If needed, the GP may adapt medication prior to hospital admission (e.g., anticoagulants). Sometimes, GP practices try to provide information to the hospital staff in advance, for example, in complex cases. Most GPs stated they were responsible for the medication plan; some responded that they were supported by their HCAs. Other indicated tasks of HCAs included answering questions from patients or forwarding questions to the GP.

GPs sometimes directly refer patients from the GP practice to the hospital (unplanned admissions). In other cases, they may be informed by an ACN or caregiver about a patient’s health deterioration and refer patients without seeing them, for example, in the case of emergencies. In these cases, relevant documents are handed over to the emergency physician, directly sent to the hospital by GPs or taken to the hospital by caregivers.

“If in an acute situation, I refer the patient to the hospital via ambulance right from my office, they don’t have everything with them or whatever. In that case I then usually have to inform third parties as well who, for instance, also have to help out.” (GP05f)

Ambulatory care nurses stated that their tasks include preparing an up-to-date medication plan which they retrieve either from their own software, or if not input in their system, from the patient or from the GP practice. If patients have medication plans from different specialists, all plans are copied and handed over to the hospital staff or the emergency physician. Prior to planned admissions, ambulatory care nurses contact the hospital to ask about medication that needs to be provided for the first day.

Hospital admission. When the patient enters the hospital, one of the main stakeholder groups involved is that of inpatient physicians, who are responsible for checking the medication plan and adapting the medication if needed. They also enter the medication into the in-house software and arrange its distribution. Inpatient nurses support inpatient physicians by both recording patients’ current medications and by communicating with stakeholders from the outpatient care setting. In addition, INs are responsible for ordering medication.

“If there are any medications lacking, there are other wards, so it’s normally pretty common to just go somewhere else to borrow some, at least for one dosage.” (IN04m)

Hospital pharmacists saw their responsibilities in recording patients’ current medications (including communication with the patient, GPs, ACNs and CGs), performing medication reviews and entering medication data into the in-house software system. They consult inpatient physicians and nurses on medication-related questions or in case of inconsistencies.

“[…] if there are any interactions, anything that [the inpatient physicians] need to be aware of; yeah, some of them come to us of their own accord too and just want us to discuss some things with the GP again […]–why the patient is now taking something, for example, that cannot be deduced from the diagnoses, right off, so to speak.” (HP03f)

Patients and caregiver in our study described their responsibilities in taking their medication and medication plan to the hospital and handing them over to the professionals.

Hospital discharge. For the transition back to the outpatient care setting, a discharge letter including an updated medication plan is created. Inpatient physicians described that this includes reconciling the medication plan from admission with the one saved in the in-house software, and creating a new plan with notes and explanations for the GP. They also contact the GP practice in special cases (before weekends, during holiday season and/or in case of expensive or special medication) to ensure continuous medical care of the patient after discharge. Lastly, their tasks include counseling the patient at discharge:

“Ultimately, a counseling session is held with each patient at discharge, and they are also given the medication plan with the discharge documents, where the new or changed medications are explicitly addressed and an explanation is provided to the patient on why this is now the case.” (IP03f)

Inpatient nurses reported that their tasks include providing the discharge medications according to the new medication plan and checking them once delivered by the hospital pharmacy. INs reported that narcotics are not provided by the hospital pharmacy and are therefore manually added to the discharge medication. INs also support inpatient physicians in discharge counseling (explaining and handing over the new medication (plan)). Moreover, one IN reported that in this capacity nurses also critically review the medication plans and address IPs if anything needs clarification.

“Where the inpatient nurses are also increasingly watching out is with all the pills–do they really have to continue being taken in the same way? Or can one maybe even reduce certain things in advance?” (IN01m)

Hospital pharmacists indicated that they review the discharge medication, prepare the medication plans including any notes for the GP (e.g., on changes, dosage, interactions and/or monitoring) and check the route of administration.

Sometimes inpatient physicians and hospital pharmacists discuss continuation and deprescription of medication before finalizing the discharge medication plan. HPs stated that they are sometimes involved in the discharge talk with the patient or in the organization of patients’ medical care after discharge together with any number of other stakeholders from both the inpatient and outpatient care settings.

Follow-up. The patients and the one informal caregiver participating considered it their responsibility, after the patient has been transferred back to outpatient care, to hand over the medication plan to the GP at the follow-up appointment (usually one day after discharge) and to collect new medication at the pharmacy. Among other tasks, GPs critically review the new medication plan and adapt it if needed (deprescribing medication, correcting dosages, changing the order, accepting or rejecting new medication).

“[I] think about the changes and take them on board or don’t even adopt them if I don’t think they make any sense.” (GP04m)

Further GP tasks include entering medication changes into their practice’s software system, handing over the new plan to patients, and if applicable, prescribing and monitoring new medication. GPs stated that all medication changes generate further tasks because they include communication with other stakeholders, e.g., with patients (explaining changes, demonstrating application/use of new medication (devices), such as inhalers, estimating whether the patient is able to implement new changes and if not, arranging support), caregivers and ambulatory care nurses (informing them about changes and giving medication-related instructions), community pharmacies (ordering medication if patient is unable to personally collect it and asking the pharmacies to hand such medications over to patients or ambulatory care services) and inpatient physicians (asking questions related to the medication plan or changes).

HCAs noted that they support GPs with both the new medication (plan) (e.g., comparing old and new medication plans, entering medication changes into the practice’s software system), and in communication with the patient (e.g., explaining and demonstrating new medication) and with inpatient nurses (e.g., forwarding questions from the GP).

Ambulatory care services forward the medication plan to the GP practice and organize new prescriptions and the medication itself.

“The GP is asked to prescribe the medications that are not in stock. In the best case, the prescriptions are collected immediately by us. If the GP is far away from us, they send […]the prescriptions by letter to the patient.” (ACN04f)

Topic 2: Challenges.

Participants identified numerous medication-related challenges described in the following.

Exchange of medication data. Participants criticized the lack of standardized structure and unified digital solutions for the exchange of medication data, which means that data often has to be transferred manually and medication plans are partially or completely handwritten. This is very time-consuming and also prone to errors, especially under time pressure.

“[…] digital file may be clearer because it is centrally stored, but it also requires a lot of clicking around when it comes to data maintenance and input […], so that that soon outweighs the advantages. […] Transferring this information into the system–whether it’s a paper, a file or a digital file–is a huge time factor and also often requires a high level of concentration, which can very quickly result in typing errors.” (IP01m)

“We then have to enter the medications manually in our software system. […] This method is pretty error-prone. […] If there is an error in the medication record or medication plan or we make a mistake in entering it in our documentation, then the error gets transmitted all the way to hospitalization.” (ACN01m)

As a result, patients often act as conduits of information from one care setting to another, which was viewed by both inpatient and outpatient stakeholders.

One clinical information scientist remarked that the exchange of information is insufficiently digitalized and that HCPs mostly rely on paper-based communication tools such as fax and e-mail.

One healthcare assistant highlighted concerns regarding the seamless transfer of medication plans:

“That is another ‘black box’ thing. Of course, medication plans are printed out in the hospital for the patient to take with them and give to the GP. But whether such a medication plan actually makes it to the GP is always a question anyway.”(HCA01f)

Medication plan. Currently, paper-based medication plans are used for exchanging information on patients’ medication between inpatient and outpatient care. However, participants noted a variety of problems relating to these plans. For example, medication plans may be outdated or incomplete (e.g., because medication prescribed by other HCPs or over-the-counter medication is lacking).

“In the case of patients who come in, where the medication plan may not have the most current date […], where you then simply approach them, for instance, and ask: ‘Is this still the current dosage?’” (HP03f)

Other problems referred to lack of medication plans, especially in the case of unplanned admissions. This is additionally challenging when patients are unable to provide valid information about their own medications and hospital staff does not have any contact person from the ambulatory care setting.

“Then often they don’t have any lists directly with them and they are also unable to directly tell me what they have taken lately.” (IP02f)

“And if, say, it’s maybe around 1:00 p.m. on Friday, then it may be extremely difficult to get this information under certain circumstances, because the GP can usually no longer be reached.” (HP02m)

GPs, in turn, remarked that medication plans after discharge are not always comprehensible, e.g., due to a lack of explanation of changes or new medications. In this context, inpatient stakeholders explained that medication plans may sometimes be incorrect or not up to date at discharge because of short-term medication changes or patients being discharged on short notice.

“In itself, I think, there is just still such a problem, where we also then don’t keep up with the situation that the inpatient physicians also like to just completely change something again at discharge or reconsider that they want to give half a tablet more after all.” (HP03f)

Medication gap. Inpatient stakeholders reported that medication gaps occur at hospital admission, for example, due to a smaller variety of drugs listed on the hospital formulary; hence some are not readily available as not in stock. This restriction requests substitutions or (time-delayed) procurement via a wholesaler. Concerns related to medication gaps were also noted as arising at hospital discharge:

“It gets difficult when medications themselves are not available in the hospital, that you cannot give enough of, which is often the case right before weekends. […] or in the case of certain drugs that you are not allowed to give patients to take with them, like morphine patches containing opiates.” (IN01m)

Outpatient stakeholders reported that the amount of discharge medication varies greatly and that it is challenging for patients as well as for ambulatory care services to organize medication in time.

“Often [patients] come on Friday afternoon and you don’t organize anything then. That means you have a gap in medication administration […] In the worst case, this can be painkillers or antibiotics.” (ACN03f)

Communication and collaboration. Participants perceived communication and cooperation with others as challenging, both within and across care settings–there is a lack of notifications to all involved stakeholders, e.g., regarding planned admissions or planned discharges. Especially ACNs stated they are not well informed, which results in organizational and time-related problems. Another deficit concerned specific instructions, e.g., related to medication adaptations before admission:

“Coordination with the physicians, especially about anticoagulation. […] It [is] still so that you have to make phone calls afterwards. Of course, this is futile and also time-consuming.” (GP01f)

Phone calls are often necessary, but it is difficult to reach the person in question and get the desired information, especially in emergencies, on evenings and weekends, resulting in information gaps that can only be filled with a delay.

“I would say that communication doesn’t work very well. […] You are then always put on hold […] or they have phone hours at times when I might also make house calls sometimes.”(GP05f)

One ACN added:

“While we do have an emergency phone, of course we don’t actually go back to the office at 8:00 p.m. to fax something. […] That’s always a bit difficult with unplanned cases.” (ACN01m)

Furthermore, participants criticized the lack of interprofessional cooperation. One ACN noted that IPs prescribe medication without “paying attention” (ACN03f), while GPs and HCAs complained about double prescriptions or prescriptions for medication that is not permitted to be prescribed by outpatient physicians.

“That they sometimes prescribe things that the patient has already had before, that is to say that something gets prescribed twice.” (HCA02f)

“Then […] occasionally medications also get prescribed that have no approvals for the [outpatient] setting.” (GP04m)

GPs also reported experiences in which inpatient physicians often make adaptations that the GPs perceive as unnecessary (e.g., interrupting anticoagulation) or even harmful to patients:

“[…] unfortunately there are relatively frequent problems at the interface, yes. […] Often they go to the hospital with 10 and come back with 15 [medications].” (GP04m)

Inpatient stakeholders, in turn, had the impression that their suggestions on medications are not welcomed by GPs:

“Most GPs just do their thing then. […] They look at their budget and think “Oh, that medication is too expensive for me”, and simply discontinue it.” (IN04m)

From the perspective of patients, there is a lack of communication regarding medications during the hospital stay. One patient would have liked to have had an explanation of her medications:

“These are your medications.’ But another explication then of who and what–[…] there wasn’t any […] I asked the night-shift nurse: “What am I actually getting?” […] and the night-shift nurse said to me: ‘You don’t need to know that; you can’t remember it anyway.” (Pat02f)

Organization. Organizational problems referred to time management, internal procedures and data safety. For example, ACNs and HCAs reported that time constraints are challenging for making arrangements or preparing documents before admission, as well as for assuming care (ACNs) or for providing timely appointments after hospital discharge (HCAs).

“This is sometimes difficult for us, because we don’t always immediately have an appointment free for the patient on the day of discharge or the following day.” (HCA04f)

Insufficient internal processes reported by inpatient stakeholders included, for example, the observation that changes in medication at admission are not transparently documented or that medication data is not centrally available for all inpatient stakeholders.

“We often have the problem that you first have to collect your information […], that all information is […] available somewhere on the ward but perhaps not yet at the moment when I need it, at least not centrally.” (HP03f)

In case of unplanned admissions, one hospital pharmacist also reported that medication plans get lost in the emergency room:

“The minor problem we still have now is, especially when the patients come in via the emergency room. The medication plans are not scanned there and get lost.”(HP01f)

Concerning data safety, HCAs felt that it is difficult to maintain confidentiality in telephone calls with hospital staff while other patients wait at the counter in the GP practice. One GP, moreover, felt that data safety hinders him from receiving necessary information:

“This data safety, yes, that just interferes, it is a hindrance and that is then sometimes very difficult. Because it’s hard to get any information.” (GP06f)

Topic 3: Solution ideas and best practice examples.

The stakeholders mentioned a variety of ideas for solutions including best practice examples for overcoming medication-related challenges.

Solutions for improving the exchange and sharing of medication-related information. Various stakeholders emphasized that medication-related information should be more easily shared, preferably through digital solutions. While one IP proposed the idea of having one harmonized medication plan “[…] if possible something like a single sheet, so that the patient doesn’t have five forms.” (IP03f), other stakeholders were already aware of the nationwide standardized patient medication plan and suggested increasing its use in the inpatient setting and at discharge. In particular, they saw great advantages in the QR code, which can be scanned when patients are admitted to hospital and helps in transferring the medication data into the in-house data software system:

“If every patient came in with a nationwide standardized medication plan that was scanned once on admission and was then in the… [system], then it would be great–that would be the optimal solution for us.” (HP03f)

One HP suggested that the medication plan should be managed by GPs but open to other physicians to add medications. In general, digital solutions were preferred in order to minimize the errors associated with entering medication data and to directly transfer patient data between different software systems. There was also the wish to import the medication plan from the patient’s health insurance card:

“That is, if such information is stored on a chip card, where everyone has access to it–from the family doctor to the hospital–accessible to all stakeholders. Because then I think no information gets lost.” (IN01m)

One IP could also imagine to “record the medications verbally, which are then automatically and digitally transcribed into the in-house software system.” (IP01m)

Optimizing medication management within the inpatient setting. One IP desired that a designated person within the inpatient setting be responsible for medication management from admission to discharge:

“[…] that would have to be a kind of liaison, one not involved in the normal daily process, […], but specifically responsible for it. And that also knows a little bit about the medications and that one organizes in such a way that the medications, which are then valid until the day of discharge, that they are then also integrated into a proper plan and perhaps given again separately to the patient.” (IP02f)

Improving the quality of medication plans. Stakeholders from both inpatient and outpatient settings (IP, IN, GP, HCA) identified potential for improving the quality of medication plans:

“[…] We as HCAs should always try to reconcile the plan or with the patient every time. When the patient picks up a prescription always asking how the medication is: ‘Are you taking it exactly as we have it specified in the plan?’” (HCA02f)

One HCA proposed the idea of bridging language barriers by compiling a list of translations and explanations of medications in different languages.

One IP and one IN shared a best practice example for dealing with ambiguous medication plans at admission, i.e., it is better to leave it out than to give the wrong medication:

“In case of doubt, if it seems strange to me and the patient doesn’t really need it because all their vitals are ok for the time being, I prefer to leave it out than administer the wrong thing, that is, until I’ve found a more reliable source.” (IP04f)

Reducing medication gaps. One HP mentioned that “pre-operative consultations” (HP02m) for elective surgeries can help to avoid medication gaps that occur due to rare and uncommon medications.

One IN suggested that patients should “bring such rare and uncommon medications” (IN02f) to the hospital at admission.

Another IN further suggested that hospital pharmacies should improve availability.

“Either the pharmacy is really staffed 24 hours a day […] or there is maybe even one person on duty who can briefly activate the unit-dose dispenser.” (IN04m)

In order to avoid medication gaps at discharge, one GP and one ACN suggested informing outpatient setting stakeholders early of a patient’s discharge date and providing a preliminary medication plan to ensure that HCPs have enough time to prepare and have everything they need in stock.

“Well, it would be very nice to receive the discharge letter as early as two days in advance, or at least a preliminary version, or the medications.” (GP03m)

Patients, HCAs and ACNs proposed providing enough medications or a prescription at discharge so that an immediate consultation at the GP practice–particularly difficult before weekends or during holiday season–is not required.

“My experience was positive because there was a weekend in between and I got [the medications] for three days. Otherwise you only get them for one day.” (patient02f)

One GP proposed reducing medication-related knowledge gaps in inpatient HCPs by providing more information on prescription medication.

“That the hospitals would also know what is possible and what is not within the scope of the mandatory health insurance scheme. […], because regulations on medications or prescriptions in the outpatient setting have become even stricter. You can’t prescribe omeprazole or pantoprazole to just anyone.” (GP04m)

One best practice example was shared by a patient looked after by a welfare institution which supported her in organizing medications after her discharge:

“Then they had them there–the C-organization is now taking care of me, and there they arranged to obtain the medicines, so that I had no problems there that any would run out in the meantime.” (patient01f)

Optimizing the layout and distribution of the discharge letter. Stakeholders from the inpatient and outpatient setting suggested several ideas for improving the discharge letter, emphasizing organized layouts based on “diagnoses and indications”(IP02f).

Moreover, ACNs and IPs suggested sending a duplicate of the discharge letter including the medication plan directly to outpatient HCPs.

“One hospital, for example, does it in such a way that a copy of the letter goes to us. We are not dependent on the GP’s discharge letter […], but have a letter ourselves that we can put in the patient’s file and where we have the current medication plan stored with us.” (ACN04f)

In addition, GPs, HCAs and ACNs expressed a desire for final discharge letters at the time of patients’ discharge from hospital.

“If we just get the letters in a timely manner–the completed ones that is, not just the preliminary letters. If it is then also about other things, which perhaps are still yet to follow, what one should do, so should arrange, or further examinations.” (GP05f)

Increasing patient responsibility and awareness. One HCA expressed a desire to see an increase in patient responsibility and awareness, e.g., informing HCPs about medication changes and keeping their patient medication plans up to date, e.g., regularly obtaining an updated medication plan from their GP and carrying it with them at all times in preparation for an unplanned admission.

“[…] cooperation on the part of the patient. That they also tell us when they no longer take a tablet, that they then say: ‘Here, I didn’t take these.’ Or that the patient when they were seen by a specialist, if there is a change in medication, which also happens a lot, that you just get notified by the patient […].” (HCA02f)

One patient would also have preferred to be more involved and proposed a “discharge medication conversation” (patient01f) to ensure that patients are informed of any medication changes during their hospital stay, including explanations regarding indications and (inter)actions. Another patient also wished for an “opportunity to read their discharge letter” (patient03f) before discharge and would have liked an opportunity to discuss medication changes with the physician.

Improving communication, collaboration and organization.

Stakeholders from both the inpatient and outpatient setting identified the need to improve communication and collaboration across care settings and considered it important for the continuity of care. GPs and Ips desired a designated contact person and improved reachability.

“[…] good, when a patient is admitted to the hospital, to send the GP a notification as well–standardized. […] because every GP would like that.” (GP03m)

The need for more direct communication between the inpatient setting and GPs was confirmed by one ACN. In addition, ACNs wanted to be involved in the process and informed of planned admissions.

“It is difficult that the wards try to go through us sometimes, which would actually be better if they would clarify this with the GP practices.” (ACN02f)

One idea for improving the organization of admissions included implementing a “hospital referral and admission management” system (ACN03w) to ensure relevant patient information on personal items such as clothing.

Topic 4: Patient-related factors.

Stakeholders shared their views on general patient-related factors that hinder or facilitate the medication-related process in transitions of care.

Sociodemographic. Stakeholders mentioned that patients’ living and financial situations play an important role in this context. Language barriers also make effective communication difficult, and the limited availability of interpreters further complicates the situation.

“In the case of people with family members who care, you get good information then too and can also work well together.” (IP03f)

Health status. Stakeholders emphasized the vulnerability of patients in need of care and pointed out that they are dependent on caregivers or family members to administer medication. In addition, cognitive impairment poses a challenge to reliable information.

“In some cases, patients no longer take care of this themselves, but are given the [medications] by the nursing service caregivers or relatives, for instance, and then just take them. Oftentimes, they don’t even know what medications [they] are taking.” (IP02f)

One inpatient physician assumed that a large number of conditions and medications for a single patient has a negative impact on the validity of information.

“Of course, the number of medications is also a crucial issue. Someone who takes only one medication can of course provide more information about it than say these poly-medicated and multimorbid patients who come with like 20 drugs. The more drugs a patient has, the more likely I think the information we get is prone to error.” (IP01m)

In the case of unplanned admissions, it is especially challenging when patients are unable to provide valid information on their own medications due to their medical condition, especially when they are unable to consent to disclosure of their health data.

“Another complicating factor is that the external institutions still [require] a signed […] declaration of consent from the patient for transfer of the data. But if the patient is so ill at the moment, they may not be able to sign it at all. Then I need the caregiver again, but I can’t reach that person at night.” (IP04f)

Personal characteristics. One of the main influencing factors with regard to patients referred to their willingness to be informed, to manage their medications, to be actively involved and to adhere to therapy plans.

“The educated, well-sorted out, organized and responsible patient. So, an adult who knows what things they take and at what time and in what dosage.” (IP04f)

Stakeholders often found it difficult to tell whether information provided by patients is reliable:

“Otherwise, of course, when you talk to patients, you always have to rely on what the patient wants to tell you. Yes, so you never have a one hundred percent guarantee that the patient will tell you everything.” (HP02m)

Patient attitudes, such as insistence on specific medications, can further complicate communication and decision-making.

“Sometimes, for instance, discussions with the patient complicate things, because they naturally also insist on certain medications. […] (IN04m)