Interactive Digital Health Tools to Engage Patients and Caregivers in Discharge Preparation: Implementation Study

Theresa E Fuller, Denise D Pong, Nicholas Piniella, Michael Pardo, Nathaniel Bessa, Catherine Yoon, Robert B Boxer, Jeffrey Lawrence Schnipper, Anuj K Dalal, Theresa E Fuller, Denise D Pong, Nicholas Piniella, Michael Pardo, Nathaniel Bessa, Catherine Yoon, Robert B Boxer, Jeffrey Lawrence Schnipper, Anuj K Dalal

Abstract

Background: Poor discharge preparation during hospitalization may lead to adverse events after discharge. Checklists and videos that systematically engage patients in preparing for discharge have the potential to improve safety, especially when integrated into clinician workflow via the electronic health record (EHR).

Objective: This study aims to evaluate the implementation of a suite of digital health tools integrated with the EHR to engage hospitalized patients, caregivers, and their care team in preparing for discharge.

Methods: We used the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to identify pertinent research questions related to implementation. We iteratively refined patient and clinician-facing intervention components using a participatory process involving end users and institutional stakeholders. The intervention was implemented at a large academic medical center from December 2017 to July 2018. Patients who agreed to participate were coached to watch a discharge video, complete a checklist assessing discharge readiness, and request postdischarge text messaging with a physician 24 to 48 hours before their expected discharge date, which was displayed via a patient portal and bedside display. Clinicians could view concerns reported by patients based on their checklist responses in real time via a safety dashboard integrated with the EHR and choose to open a secure messaging thread with the patient for up to 7 days after discharge. We used mixed methods to evaluate our implementation experience.

Results: Of 752 patient admissions, 510 (67.8%) patients or caregivers participated: 416 (55.3%) watched the video and completed the checklist, and 94 (12.5%) completed the checklist alone. On average, 4.24 concerns were reported per each of the 510 checklist submissions, most commonly about medications (664/2164, 30.7%) and follow-up (656/2164, 30.3%). Of the 510 completed checklists, a member of the care team accessed the safety dashboard to view 210 (41.2%) patient-reported concerns. For 422 patient admissions where postdischarge messaging was available, 141 (33.4%) patients requested this service; of these, a physician initiated secure messaging for 3 (2.1%) discharges. Most patient survey participants perceived that the intervention promoted self-management and communication with their care team. Patient interview participants endorsed gaps in communication with their care team and thought that the video and checklist would be useful closer toward discharge. Clinicians participating in focus groups perceived the value for patients but suggested that low awareness and variable workflow regarding the intervention, lack of technical optimization, and inconsistent clinician leadership limited the use of clinician-facing components.

Conclusions: A suite of EHR-integrated digital health tools to engage patients, caregivers, and clinicians in discharge preparation during hospitalization was feasible, acceptable, and valuable; however, important challenges were identified during implementation. We offer strategies to address implementation barriers and promote adoption of these tools.

Trial registration: ClinicalTrials.gov NCT03116074; https://ichgcp.net/clinical-trials-registry/NCT03116074.

Keywords: care transitions; health information technology; implementation science; patient engagement.

Conflict of interest statement

Conflicts of Interest: JS was the recipient of an investigator-initiated grant from Mallinckrodt Pharmaceuticals to study opioid-related adverse drug events and an investigator-initiated grant from Portola Pharmaceuticals to study patients who decline inpatient venous thromboembolism prophylaxis. The remaining authors have no competing interests to declare.

©Theresa E Fuller, Denise D Pong, Nicholas Piniella, Michael Pardo, Nathaniel Bessa, Catherine Yoon, Robert B Boxer, Jeffrey Lawrence Schnipper, Anuj K Dalal. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 28.04.2020.

Figures

Figure 1
Figure 1
Patient-centered discharge toolkit: Enhancements to the EHR-integrated digital health infrastructure. PSLL: Patient Safety Learning Laboratory; EHR: electronic health record.
Figure 2
Figure 2
Discharge checklist and video.
Figure 3
Figure 3
Checklist submission and review. EHR: electronic health record.

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