Virtual Continuity and Its Impact on Complex Hospitalized Patients' Care

Communication between physicians caring for a patient in the hospital and that patient's primary care provider is less than optimal, and can lead to diminished health care quality and safety. This project will lead to better communication between physicians and could decrease medication errors that tend to occur as the patient goes from hospital to home.

Study Overview

• Status: Completed
• Conditions: Automated Communication Tools; Complex Medical Patients
• Intervention / Treatment: Other: Automated communication tools

Detailed Description

Communication between physicians caring for hospitalized patients and those patients' primary care providers (PCPs) is often suboptimal. Hospital-based information systems can improve communication by automating information exchange between hospital physicians and PCPs, and perhaps, as a result, improve the quality and safety of health care. MedTrak, the University of Pittsburgh Medical Center (UPMC) electronic physician communication tool, has proven successful and is poised to move forward with an initiative the investigators call virtual continuity, allowing PCPs to follow their patients electronically if they cannot do so physically. Virtual continuity will include: emails to PCPs triggered by clinical events with embedded links to electronic medical record data and communication portals, medication lists electronically delivered to PCPs at admission and discharge, and immediate PCP notification of discharge with pertinent clinical details. To evaluate virtual continuity, the investigators will examine the frequency of discharge medication errors in complex medical patients using a pre-post study design of virtual continuity compared to usual communication. Medication errors will be ascertained using accepted methods. The investigators will also investigate differences in rehospitalization, post discharge emergency department visit and PCP follow up rates. The IT cost of implementing and maintaining the virtual continuity intervention will also be assessed. Virtual continuity will allow PCPs to participate more directly in the care of their hospitalized patients. Improved communication could lead to higher-quality patient care and greater patient care safety for hospitalized patients with complex medical problems.

• Study Type: Interventional
• Enrollment (Actual): 835
• Phase: Phase 3

Contacts and Locations

Study Locations

• United States
  • Pennsylvania
    • Pittsburgh, Pennsylvania, United States, 15213-2582
      • UPMC Presbyterian Hospital

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Are admitted to UPMC Presbyterian General Medicine, Geriatrics, Cardiology, or Surgery inpatient services;
• Are 18 years of age or older;
• Are currently receiving 5 or more medications;
• Have 2 or more comorbid conditions present, defined using the Elixhauser comorbidity system (Med Care 1998;36:8-27 and Med Care. 2005 Nov; 43(11): 1130-9 ). These comorbidities are: congestive heart failure, cardiac arrhythmias, valvular disease, pulmonary circulation disorders, peripheral vascular disorders, hypertension, paralysis, other neurologic disorders, chronic pulmonary disease, diabetes uncomplicated, diabetes complicated, hypothyroidism, renal failure, liver disease, peptic ulcer disease excluding bleeding, AIDS/HIV disease, lymphoma, metastatic cancer, solid tumor without metastasis, rheumatoid arthritis/collagen vascular diseases, coagulopathy, obesity, weight loss, fluid and electrolyte disorders, blood loss anemia, deficiency anemias, alcohol abuse, drug abuse, psychoses, and depression
• Have a Primary Care Physician who has outpatient data included on EPIC electronic health record.

Exclusion Criteria:

• Are admitted to critical care units;
• Are admitted from skilled nursing facilities;
• Have dementia;
• Were previously enrolled in the study
• Are organ transplant recipients

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Health Services Research
• Allocation: Non-Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
No Intervention: (Usual) MedTrak system of PCP notification; MedTrak, the information system used by the University of Pittsburgh Medical Center (UPMC), currently notifies PCPs when patients are admitted and discharged from the hospital.
Experimental: Automated communication tools; An enhanced version of MedTrak (the present system of PCP notification). Electronic medical record links will be developed and used to allow automated communication with the PCP.	Other: Automated communication tools; Automated communication tools will include: PCP notification of patient admission and location; Data on medications begun on admission; Automated alerts on changes in patient status and location while the patient is hospitalized; Links to the EMR and to hospital physician contact information on all email alerts; Real-time delivery of discharge information (medications, instructions, and follow-up) to the PCP; Automatic reporting to PCPs of test results pending at discharge; Electronic delivery of final discharge summaries

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Medication Errors at Hospital Discharge	Medication name, dose, and frequency of administration for patient pre-admission medications will be recorded. Medications received during the hospitalization and discharge medications will be obtained by medical record review following hospital discharge. Pre-admission medications will be compared to discharge medications and differences will be considered discharge medication variances. Two trained pharmacists will independently review medication variances to determine clinical indications or medication errors.	Approximately 1-30 days

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Patient PCP Visits, Emergency Room Visits and Rehospitalizations Within 30 Days Post-discharge.	Details regarding patient PCP follow-up office appointments, ER visits and rehospitalizations occuring within 30 days post-discharge will be collected from the EMR.	Within 30 post-discharge from hospital

Collaborators and Investigators

• Sponsor: University of Pittsburgh
• Collaborators: Agency for Healthcare Research and Quality (AHRQ)
• Investigators: Principal Investigator: Kenneth J Smith, MD, MS, University of Pittsburgh Medical Center, University of Pittsburgh

Publications and helpful links

General Publications

• Kripalani S, Jackson AT, Schnipper JL, Coleman EA. Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists. J Hosp Med. 2007 Sep;2(5):314-23. doi: 10.1002/jhm.228.
• Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007 Feb 28;297(8):831-41. doi: 10.1001/jama.297.8.831.
• Halasyamani L, Kripalani S, Coleman E, Schnipper J, van Walraven C, Nagamine J, Torcson P, Bookwalter T, Budnitz T, Manning D. Transition of care for hospitalized elderly patients--development of a discharge checklist for hospitalists. J Hosp Med. 2006 Nov;1(6):354-60. doi: 10.1002/jhm.129.
• Coleman EA, Boult C; American Geriatrics Society Health Care Systems Committee. Improving the quality of transitional care for persons with complex care needs. J Am Geriatr Soc. 2003 Apr;51(4):556-7. doi: 10.1046/j.1532-5415.2003.51186.x. No abstract available.
• Coleman EA, Mahoney E, Parry C. Assessing the quality of preparation for posthospital care from the patient's perspective: the care transitions measure. Med Care. 2005 Mar;43(3):246-55. doi: 10.1097/00005650-200503000-00007.

Study record dates

Study Major Dates

• Study Start: August 1, 2010
• Primary Completion (Actual): January 1, 2013
• Study Completion (Actual): January 1, 2013

Study Registration Dates

• First Submitted: July 15, 2011
• First Submitted That Met QC Criteria: July 18, 2011
• First Posted (Estimate): July 19, 2011

Study Record Updates

• Last Update Posted (Estimate): April 16, 2015
• Last Update Submitted That Met QC Criteria: March 27, 2015
• Last Verified: March 1, 2015

More Information

Terms related to this study

• Keywords: Medication errors; Automated Communication Tools; PCP communication
• Other Study ID Numbers: 3130920