Insights from a study published recently in the Journal of the American Medical Informatics Association may point the way to a new approach for better preparing patients for discharge from the hospital.
The goal of the study was to see if it was possible to facilitate more proactive discharge preparations for patients or their designated caregivers by using digital health apps integrated with the electronic health record (EHR).
The investigators administered a structured checklist and a video via mobile device through a patient portal. Participants were also given a web-based survey at least 24 hours prior to their anticipated discharge. The checklist responses were instantly available to clinicians to review via a safety dashboard accessible from the EHR.
“We did this study because discharge can be a chaotic time for patients and their caregivers with lots of information, lots of new changes, medications, and follow-up instructions,” said corresponding study author Anuj K Dalal, MD, an associate physician at Brigham and Women’s Hospital and an associate professor of medicine at Harvard Medical School, Boston, Massachusetts. “It can also be hectic for hospital-based clinicians, who are often pulled in a multitude of directions, and under considerable pressure to get patients discharged efficiently and safely.”
The current study included 673 general medicine patients older than 18 years who were hospitalized for at least 24 hours at Brigham and Women’s Hospital. Patients who completed the checklist had a longer length of stay. However, the mean length of stay was significantly longer after implementation of the program compared with before implementation (10.13 vs 6.21 days). While it was not what the research team predicted or hoped, as a non-randomized study there were likely other factors at play that could have confounded the results, according to the investigators.
“For example, patients who completed the checklist had many comorbidities, were sicker, and were less activated or engaged in their care overall,” Dr Dalal said. “I think the results are likely to be positively received in the medical community in terms of examining more closely what we as clinicians can do to better the process of discharging patients.”
If clinicians proactively identify patients’ concerns a day or so before their anticipated discharge date, then in theory this should decrease the amount of time spent reacting to these concerns on the day of discharge. Dr Dalal said many of the instructions clinicians provide on the day of discharge can be overwhelming and difficult to remember. In the current study, the checklist results were sent to the EHR, but it still required clinicians to look at the results. The investigators avoided actively notifying clinicians to minimize the risk of “alert fatigue”.
Now is the time to consider how best to use new technology to optimize healthcare delivery systems and workflows in a way that centers on the patients’ concerns, especially around the time of discharge, Dr Dalal said. “That is truly the only way to deliver high quality and safe healthcare,” Dr Dalal said. “If this can be efficiently and effectively done, then ultimately this information can streamline the care process and help clinicians identify what is most important to patients and respond to it quickly.”
Steven Nurkin, MD, a surgical oncologist and an associate professor of oncology at Roswell Park Comprehensive Cancer Center, Buffalo, New York, said patient portals can be used much more effectively than is currently the case. “We need to better leverage current tech in this space to improve quality and efficiency, while reducing costs.” Artificial intelligence (AI) combined with wearable technology to record vital signs, test results, and other clinical information can better identify when patients are starting to develop concerning symptoms or issues, he said.
AI communication tools like chatbots and interactive voice response (IVR) systems, which effectively remove the need for a real person on the phone, can intervene and address more straightforward issues earlier on, Dr Nurkin explained.
Bethany M. Sarosiek, RN, MSN, who is with the Enhanced Recovery After Surgery (ERAS) Program at the University of Virginia (UVA) Health System in Charlottesville, Virginia, said her institution uses the EPIC MyChart patient portal to communicate directly with patients. She said it has helped to streamline information delivery and to ensure fast communication, particularly during the COVID-19 pandemic when clinical situations change day-to-day. “It has allowed us to send information about changing COVID policies, visitation restrictions, and modification of schedules in almost real time,” Sarosiek said. “While versatile, the EPIC MyChart portal has proven challenging at times since it often routes provider messages to a collective in-basket, which may confound the patient/provider relationship.”
This portal also requires active engagement by the patient to sign up for participation. Sarosiek said the best routes to assure sign-up or ease user burden are still being explored. “I believe ‘alert fatigue’ is always a potential issue with any electronic system we use. It’s a constant challenge to find the right balance between providing enough information to allow for full understanding at the risk of information overload,” Sarosiek said.
As part of the colorectal ERAS program, UVA Health worked alongside a local digital technology company, Willowtree®, to create a user-friendly patient platform to assist with patient education delivery. The platform issued notifications and reminders, and direct provider communication. “As the title suggests, the ERAS program aims to provide an improved experience for patients around major surgery, with its primary goal of patient involvement in his/her own care. The UVA ERAS app was created to support this goal,” Sarosiek said.
With this approach, the app itself provides information “bites” around the time of the surgery, including medication instructions, information on preparation for surgery, parking instructions, and daily goal reminders. After discharge, patients receive reminders about appointments, and they are asked about their pain and wound healing. The patients have a direct way to communicate with their care team if issues arise. “With the support of this app, our ERAS program has continued to improve post-surgical outcomes and minimize postoperative complications, all while keeping patients engaged with their care teams and improving overall satisfaction with the ERAS program,” Sarosiek said.
While UVA Health’s ERAS app is user-friendly and visually appealing, Sarosiek said the development and production costs were limiting factors in expanding its use to additional ERAS programs. In the future, it is hoped that barriers, such as high production costs, will come down and improve patient care.
Dalal AK, Pniella N, Fuller TE, et al. Evaluation of electronic health record-integrated digital health tools to engage hospitalized patients in discharge preparation. Published online January 19, 2021. J Am Med Inform Assoc. doi:10.1093/jamia/ocaa321