Evaluation of electronic health record-integrated digital health tools to engage hospitalized patients in discharge preparation

Effect of digital tools to promote hospital quality and safety on adverse events after discharge

OBJECTIVES

Post-discharge adverse events (AEs) are common and heralded by new and worsening symptoms (NWS). We evaluated the effect of electronic health record (EHR)-integrated digital tools designed to promote quality and safety in hospitalized patients on NWS and AEs after discharge.

MATERIALS AND METHODS

Adult general medicine patients at a community hospital were enrolled. We implemented a dashboard which clinicians used to assess safety risks during interdisciplinary rounds. Post-implementation patients were randomized to complete a discharge checklist whose responses were incorporated into the dashboard. Outcomes were assessed using EHR review and 30-day call data adjudicated by 2 clinicians and analyzed using Poisson regression. We conducted comparisons of each exposure on post-discharge outcomes and used selected variables and NWS as independent predictors to model post-discharge AEs using multivariable logistic regression.

RESULTS

A total of 260 patients (122 pre, 71 post [dashboard], 67 post [dashboard plus discharge checklist]) enrolled. The adjusted incidence rate ratios (aIRR) for NWS and AEs were unchanged in the post- compared to pre-implementation period. For patient-reported NWS, aIRR was non-significantly higher for dashboard plus discharge checklist compared to dashboard participants (1.23 [0.97,1.56], P = .08). For post-implementation patients with an AE, aIRR for duration of injury (>1 week) was significantly lower for dashboard plus discharge checklist compared to dashboard participants (0 [0,0.53], P < .01). In multivariable models, certain patient-reported NWS were associated with AEs (3.76 [1.89,7.82], P < .01).

DISCUSSION

While significant reductions in post-discharge AEs were not observed, checklist participants experiencing a post-discharge AE were more likely to report NWS and had a shorter duration of injury.

CONCLUSION

Interventions designed to prompt patients to report NWS may facilitate earlier detection of AEs after discharge.

CLINICALTRIALS.GOV

NCT05232656.

Strategies to promote patient-centeredness within the healthcare industry: A grey-based multicriteria decision making methods

RATIONALE

The international policy agenda has recently advocated for the development of patient-centeredness in healthcare service delivery. Consequently, various stakeholders in the healthcare systems have expressed a vital need for identifying strategies and tools that can enhance patient-centeredness.

AIMS AND OBJECTIVES

The objective of this paper was to prioritise and benchmark the strategies that can improve patient-centeredness in healthcare service delivery.

METHOD

We employed a multi-stage research scenario that consisted of two phases: a phase including of a scoping review to identify the current strategies to improve patient-centeredness (PC); And, a phase including of a multicriteria best-worst method to assign weights to PC principles, and a questionnaire administered to a sample of experts for benchmarking the strategies derived from the literature using the Grey Multi-Attributive Border Approximation Area Comparison (MABAC-G) method.

RESULTS

The most important principle of patient-centeredness was deemed to be access to care, while telehealth tools and Electronic Health Information Systems were respectively suggested as the most efficacious platforms for promoting patient-centeredness.

CONCLUSION

We recommend that administrators and policy makers in the healthcare industry prioritise the implementation and research of strategies such as telehealth tools and electronic health information systems to enhance access and patient-centeredness in the healthcare systems.

Digital health interventions to improve adherence to oral antipsychotics among patients with schizophrenia: a scoping review

OBJECTIVES

To assess the current evidence on the potential of digital health interventions (DHIs) to improve adherence to oral antipsychotics among patients with schizophrenia by assessing the methodologies, feasibility and effectiveness of DHIs as well as the perceptions of relevant stakeholders.

DESIGN

The scoping review was conducted based on the methodologies outlined by Levac et al and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines.

DATA SOURCES

PubMed, Embase, Web of Science, Scopus, CINAHL, PsycINFO and the Cochrane Library were searched in August 2023 to identify relevant publications from the previous decade.

ELIGIBILITY CRITERIA

Studies published in English focused on improving medication adherence among adult patients with schizophrenia or schizoaffective disorder via DHIs were selected. Protocols, editorials, comments, perspectives, reviews, correspondence and conference abstracts were excluded.

DATA EXTRACTION AND SYNTHESIS

The extracted data included general information about the study, framework, participants, features and strategies of DHIs, measurement tools for adherence used, and main findings.

RESULTS

In total, 64 studies were included in the qualitative synthesis. Features used in DHIs to improve medication adherence included phone calls, text messages, mobile apps, sensors, web-based platforms and electronic devices. Strategies included medication reminders and monitoring, providing medication-related information and suggestions, other illness management suggestions and individual support. Texting and mobile apps were commonly used as medication reminders and monitoring methods. Additionally, the use of sensors combined with other digital technologies has garnered significant attention. All the interventions were considered acceptable and feasible, and several were assessed in pilot trials. Preliminary findings suggest that DHIs could enhance medication adherence in patients with schizophrenia. However, further validation of their effectiveness is required.

CONCLUSION

DHIs are a promising approach to enhancing medication adherence among patients with schizophrenia. Future interventions should be interactive, focusing on user preference, experience and privacy.

Interest in using patient portals among adolescents in mental health care - a cross-sectional study

INTRODUCTION

Adolescents in mental health care may benefit from using patient portals to access personalised information about their health and treatment. While no studies have considered the interest in using patient portals among adolescents in mental health care, factors such as patient activation, self-reported health, depressive symptoms, diagnosis, healthcare utilisation, and eHealth literacy have been found to be associated with interest in and use of patient portals in other patient groups. Therefore, the aim was to explore the associations between interest in using patient portals and patient activation, self-reported health, depressive symptoms, diagnosis, healthcare utilisation and eHealth literacy among adolescents in specialist mental health care.

METHODS

A cross-sectional study among adolescents between 12 and 18 years of age receiving or having received treatment at four different specialist child and adolescent mental healthcare services across Norway. The adolescents´ answers to the questionnaire were linked to data on their healthcare utilisation and ICD-10 diagnoses from the Norwegian Patient Registry. The data were analysed using descriptive statistics and bivariate tests.

RESULTS

The 53 adolescents who participated, had a mean age of 15 years and 68% of them identified as female. Two out of three (64%) were interested in using patient portals. Most of the factors were not associated with interest in using patient portals. However, adolescents with mental and behavioural disorders (F diagnoses, 75% interested) were more interested in using patient portals compared to those with symptoms and signs involving cognition, perception, emotional state, and behaviour (R diagnoses, 31% interested).

CONCLUSION

Except for mental health diagnosis, this study did not identify any specific factors likely to impact patient portal interest among adolescents in specialist mental health care.

Developing, pilot testing, and refining requirements for 3 EHR-integrated interventions to improve diagnostic safety in acute care: a user-centered approach

Objective

To describe a user-centered approach to develop, pilot test, and refine requirements for 3 electronic health record (EHR)-integrated interventions that target key diagnostic process failures in hospitalized patients.

Materials and Methods

Three interventions were prioritized for development: a Diagnostic Safety Column (DSC) within an EHR-integrated dashboard to identify at-risk patients; a Diagnostic Time-Out (DTO) for clinicians to reassess the working diagnosis; and a Patient Diagnosis Questionnaire (PDQ) to gather patient concerns about the diagnostic process. Initial requirements were refined from analysis of test cases with elevated risk predicted by DSC logic compared to risk perceived by a clinician working group; DTO testing sessions with clinicians; PDQ responses from patients; and focus groups with clinicians and patient advisors using storyboarding to model the integrated interventions. Mixed methods analysis of participant responses was used to identify final requirements and potential implementation barriers.

Results

Final requirements from analysis of 10 test cases predicted by the DSC, 18 clinician DTO participants, and 39 PDQ responses included the following: DSC configurable parameters (variables, weights) to adjust baseline risk estimates in real-time based on new clinical data collected during hospitalization; more concise DTO wording and flexibility for clinicians to conduct the DTO with or without the patient present; and integration of PDQ responses into the DSC to ensure closed-looped communication with clinicians. Analysis of focus groups confirmed that tight integration of the interventions with the EHR would be necessary to prompt clinicians to reconsider the working diagnosis in cases with elevated diagnostic error (DE) risk or uncertainty. Potential implementation barriers included alert fatigue and distrust of the risk algorithm (DSC); time constraints, redundancies, and concerns about disclosing uncertainty to patients (DTO); and patient disagreement with the care team's diagnosis (PDQ).

Discussion

A user-centered approach led to evolution of requirements for 3 interventions targeting key diagnostic process failures in hospitalized patients at risk for DE.

Conclusions

We identify challenges and offer lessons from our user-centered design process.

Early Expected Discharge Date Accuracy During Hospitalization: A Multivariable Analysis

INTRODUCTION

Accurate estimation of an expected discharge date (EDD) early during hospitalization impacts clinical operations and discharge planning.

METHODS

We conducted a retrospective study of patients discharged from six general medicine units at an academic medical center in Boston, MA from January 2017 to June 2018. We retrieved all EDD entries and patient, encounter, unit, and provider data from the electronic health record (EHR), and public weather data. We excluded patients who expired, discharged against medical advice, or lacked an EDD within the first 24 h of hospitalization. We used generalized estimating equations in a multivariable logistic regression analysis to model early EDD accuracy (an accurate EDD entered within 24 h of admission), adjusting for all covariates and clustering by patient. We similarly constructed a secondary multivariable model using covariates present upon admission alone.

RESULTS

Of 3917 eligible hospitalizations, 890 (22.7%) had at least one accurate early EDD entry. Factors significantly positively associated (OR > 1) with an accurate early EDD included clinician-entered EDD, admit day and discharge day during the work week, and teaching clinical units. Factors significantly negatively associated (OR < 1) with an accurate early EDD included Elixhauser Comorbidity Index ≥ 11 and length of stay of two or more days. C-statistics for the primary and secondary multivariable models were 0.75 and 0.60, respectively.

CONCLUSIONS

EDDs entered within the first 24 h of admission were often inaccurate. While several variables from the EHR were associated with accurate early EDD entries, few would be useful for prospective prediction.

A Targeted Discharge Planning for High-Risk Readmissions: Focus on Patients and Caregivers

PURPOSE OF STUDY

Racial and ethnic minorities with socioeconomic disadvantages are vulnerable to 30-day hospital readmissions. A 16-week quality improvement (QI) project aimed to decrease readmissions of the vulnerable patient populations through tailored discharge planning. The project evaluated the effectiveness of using a 25-item checklist to increase patients' and caregivers' health knowledge, skills, and willingness for self-care and decrease readmissions.

PRIMARY PRACTICE SETTING

The project took place in an inner-city teaching hospital in the Mid-Atlantic region.

METHODOLOGY AND PARTICIPANTS

A casual comparative design compared readmissions of the before-intervention group (May 1-July 31, 2021) and the after-intervention group (August 1-October 31, 2021). A pre- and postintervention design evaluated the effectiveness of a 25-item checklist by analyzing the differences of Patient Activation Measure (PAM) pre- and postintervention survey scores and levels in the after-intervention group. Participants were General Medicine Unit patients 18 years or older who had Medicare Fee-for-Service, resided in 10 zip codes near the hospital, and were discharged home.

RESULTS

Of 30 patients who received the intervention, one patient was readmitted compared with 11 readmissions from 58 patients who did not receive the intervention. The readmission rate was decreased from 19% to 4% during the 16-week project: 11 (19%) versus 1 (4%), p = .038. After receiving the intervention, patients' PAM scores were increased by 8.55, t(22) = 2.67, p < .014. Three patients had a lower postintervention survey level, whereas 12 patients obtained a higher postintervention survey level (p = .01). The increase in scores and levels supported that the intervention effectively improved patients' self-management knowledge, skill, and willingness for self-care.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

The QI project showed that the hospital could partner with patients at high risk for readmission and their caregivers. Accurate evaluation of patients' health knowledge, skills, and willingness for self-care was essential for sufficient discharge planning. Tailored use of the checklist improved patients' self-activation and functionally facilitated patients' and caregivers' care needs and capabilities. The checklist was statistically and clinically effective in decreasing 30-day hospital readmissions of vulnerable patient populations.

Digital public health leadership in the global fight for health security

The COVID-19 pandemic highlighted the need to prioritise mature digital health and data governance at both national and supranational levels to guarantee future health security. The Riyadh Declaration on Digital Health was a call to action to create the infrastructure needed to share effective digital health evidence-based practices and high-quality, real-time data locally and globally to provide actionable information to more health systems and countries. The declaration proposed nine key recommendations for data and digital health that need to be adopted by the global health community to address future pandemics and health threats. Here, we expand on each recommendation and provide an evidence-based roadmap for their implementation. This policy document serves as a resource and toolkit that all stakeholders in digital health and disaster preparedness can follow to develop digital infrastructure and protocols in readiness for future health threats through robust digital public health leadership.

Development of a Primary Care Transitions Clinic in an Academic Medical Center

INTRODUCTION

Transitions of care experiences leave patients vulnerable to adverse outcomes, including readmissions, worsening symptoms, and reductions in functional status.

AIM

To describe and evaluate a primary care transitions clinic that serves patients with medical and/or social needs that must be addressed prior to establishment of primary care.

SETTING

Brigham Health, an academic medical center in Boston, MA.

PROGRAM DESCRIPTION

The transitions clinic opened within an existing primary care practice in January 2019. It employs one full-time nurse care coordinator and one full-time medical assistant, and is staffed by one primary care physician (PCP) or nurse practitioner each weekday afternoon. Both medical and social diagnoses that require follow-up post-discharge are addressed. Patients with any insurance are seen as many times as necessary until PCP care is established.

PROGRAM EVALUATION

In the year after its establishment (January 20, 2019, to January 19, 2020), the transitions clinic received 498 referrals (73.2% from the emergency department (ED), 23.3% from inpatient), with 207 patients ultimately seen. Patients were seen 5 (median; IQR 4-6) work days post-discharge, with 2 (median; IQR 1-3) visits per patient. Patients seen in the transitions clinic had significantly fewer ED visits than a comparator cohort referred to Brigham Health Primary Care after ED or hospital discharge in the year prior (January 20, 2018, to January 20, 2019). Patients seen in the transitions clinic additionally had significantly fewer ED visits and hospitalizations in the three months post-referral than in the three months pre-referral. The most common social determinants addressed by the clinic's nurse coordinator were insurance, transportation, and housing.

DISCUSSION

A primary care transitions clinic can provide accessible, attentive care post-discharge with positive effects on healthcare utilization. Availability of a multidisciplinary team that can see patients for repeated visits until establishment of PCP care was a key success factor for the transitions clinic.

User-centered design of a scalable, electronic health record-integrated remote symptom monitoring intervention for patients with asthma and providers in primary care

OBJECTIVE

To determine user and electronic health records (EHR) integration requirements for a scalable remote symptom monitoring intervention for asthma patients and their providers.

METHODS

Guided by the Non-Adoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) framework, we conducted a user-centered design process involving English- and Spanish-speaking patients and providers affiliated with an academic medical center. We conducted a secondary analysis of interview transcripts from our prior study, new design sessions with patients and primary care providers (PCPs), and a survey of PCPs. We determined EHR integration requirements as part of the asthma app design and development process.

RESULTS

Analysis of 26 transcripts (21 patients, 5 providers) from the prior study, 21 new design sessions (15 patients, 6 providers), and survey responses from 55 PCPs (71% of 78) identified requirements. Patient-facing requirements included: 1- or 5-item symptom questionnaires each week, depending on asthma control; option to request a callback; ability to enter notes, triggers, and peak flows; and tips pushed via the app prior to a clinic visit. PCP-facing requirements included a clinician-facing dashboard accessible from the EHR and an EHR inbox message preceding the visit. PCP preferences diverged regarding graphical presentations of patient-reported outcomes (PROs). Nurse-facing requirements included callback requests sent as an EHR inbox message. Requirements were consistent for English- and Spanish-speaking patients. EHR integration required use of custom application programming interfaces (APIs).

CONCLUSION

Using the NASSS framework to guide our user-centered design process, we identified patient and provider requirements for scaling an EHR-integrated remote symptom monitoring intervention in primary care. These requirements met the needs of patients and providers. Additional standards for PRO displays and EHR inbox APIs are needed to facilitate spread.