Patient Recommendations to Improve the Implementation of and Engagement With Portals in Acute Care: Hospital-Based Qualitative Study.

BACKGROUND: The inclusion of patient portals into electronic health records in the inpatient setting lags behind progress in the outpatient setting. OBJECTIVE: The aim of this study was to understand patient perceptions of using a portal during an episode of acute care and explore patient-perceived barriers and facilitators to portal use during hospitalization. METHODS: We utilized a mixed methods approach to explore patient experiences in using the portal during hospitalization. All patients received a tablet with a brief tutorial, pre- and postuse surveys, and completed in-person semistructured interviews. Qualitative data were coded using thematic analysis to iteratively develop 18 codes that were integrated into 3 themes framed as patient recommendations to hospitals to improve engagement with the portal during acute care. Themes from these qualitative data guided our approach to the analysis of quantitative data. RESULTS: We enrolled 97 participants: 53 (53/97, 55%) women, 44 (44/97, 45%) nonwhite with an average age of 48 years (19-81 years), and the average length of hospitalization was 6.4 days. A total of 47 participants (47/97, 48%) had an active portal account, 59 participants (59/97, 61%) owned a smartphone, and 79 participants (79/97, 81%) accessed the internet daily. In total, 3 overarching themes emerged from the qualitative analysis of interviews with these patients during their hospital stay: (1) hospitals should provide both access to a device and bring-your-own-device platform to access the portal; (2) hospitals should provide an orientation both on how to use the device and how to use the portal; and (3) hospitals should ensure portal content is up to date and easy to understand. CONCLUSIONS: Patients independently and consistently identified basic needs for device and portal access, education, and usability. Hospitals should prioritize these areas to enable successful implementation of inpatient portals to promote greater patient engagement during acute care. TRIAL REGISTRATION: ClinicalTrials.gov NCT00102401; https://clinicaltrials.gov/ct2/show/NCT01970852.

A randomized controlled trial to improve engagement of hospitalized patients with their patient portals.

Objectives: To test a patient-centered, tablet-based bedside educational intervention in the hospital and to evaluate the efficacy of this intervention to increase patient engagement with their patient portals during hospitalization and after discharge. Materials and Methods: We conducted a randomized controlled trial of adult patients admitted to the hospitalist service in one large, academic medical center. All participants were supplied with a tablet computer for 1 day during their inpatient stay and assistance with portal registration and initial login as needed. Additionally, intervention group patients received a focused bedside education to demonstrate key functions of the portal and explain the importance of these functions to their upcoming transition to post-discharge care. Our primary outcomes were proportion of patients who logged into the portal and completed specific tasks after discharge. Secondary outcomes were observed ability to navigate the portal before discharge and self-reported patient satisfaction with bedside tablet use to access the portal. Results: We enrolled 97 participants (50 intervention; 47 control); overall 57% logged into their portals ≥1 time within 7 days of discharge (58% intervention vs. 55% control). Mean number of logins was higher for the intervention group (3.48 vs. 2.94 control), and mean number of specific portal tasks performed was higher in the intervention group; however, no individual comparison reached statistical significance. Observed ability to login and navigate the portal in the hospital was higher for the intervention group (64% vs. 60% control), but only 1 specific portal task was significant (view provider messaging tab: 92% vs. 77% control, P = .04). Time needed to deliver the intervention was brief (<15 min for 80%), and satisfaction with the bedside tablet to access the portal was high in the intervention group (88% satisfied/very satisfied). Conclusion: Our intervention was highly feasible and acceptable to patients, and we found a highly consistent, but statistically non-significant, trend towards higher inpatient engagement and post-discharge use of key portal functions among patients in the intervention group.

Automating Venous Thromboembolism Risk Calculation Using Electronic Health Record Data upon Hospital Admission: The Automated Padua Prediction Score.

BACKGROUND: Venous thromboembolism (VTE) risk scores assist providers in determining the relative benefit of prophylaxis for individual patients. While automated risk calculation using simpler electronic health record (EHR) data is feasible, it lacks clinical nuance and may be less predictive. Automated calculation of the Padua Prediction Score (PPS), requiring more complex input such as recent medical events and clinical status, may save providers time and increase risk score use. OBJECTIVE: We developed the Automated Padua Prediction Score (APPS) to auto-calculate a VTE risk score using EHR data drawn from prior encounters and the first 4 hours of admission. We compared APPS to standard practice of clinicians manually calculating the PPS to assess VTE risk. DESIGN: Cohort study of 30,726 hospitalized patients. APPS was compared to manual calculation of PPS by chart review from 300 randomly selected patients. MEASUREMENTS: Prediction of hospital-acquired VTE not present on admission. RESULTS: Compared to manual PPS calculation, no significant difference in average score was found (5.5 vs. 5.1, P = 0.073), and area under curve (AUC) was similar (0.79 vs. 0.76). Hospital- acquired VTE occurred in 260 (0.8%) of 30,726 patients. Those without VTE averaged APPS of 4.9 (standard deviation [SD], 2.6) and those with VTE averaged 7.7 (SD, 2.6). APPS had AUC = 0.81 (confidence interval [CI], 0.79-0.83) in patients receiving no pharmacologic prophylaxis and AUC = 0.78 (CI, 0.76- 0.82) in patients receiving pharmacologic prophylaxis. CONCLUSIONS: Automated calculation of VTE risk had similar ability to predict hospital-acquired VTE as manual calculation despite differences in how often specific scoring criteria were considered present by the 2 methods. Journal of Hospital Medicine 2017;12: 231- 237.

Half-life of a printed handoff document.

BACKGROUND: Printed handoff documents are nearly universally present in the pockets of providers taking inhouse call. They are frequently used to answer clinical questions. However, the static nature of printed documents makes it likely that information will quickly become inaccurate as a result of ongoing management. This increases the potential for medical errors, especially in clinical services which rely heavily on printed documents for ongoing patient management. OBJECTIVE: To measure the average time to potential inaccuracy, represented as the 'half-life' of printed handoff documents. DESIGN, SETTING, PARTICIPANTS: Cross-sectional analysis of 100 adult inpatients during a single 24 h period at an academic medical centre in 2014. MAIN OUTCOME AND MEASURE: The half-life was defined as the time at which half of the patients would be expected to have inaccurate information on a printed handoff document, based on review of orders which populate data fields on these printed handoff documents. RESULTS: In our sample, the half-life was 6 h on the 12 h night shift and 3.3 h on the day shift. We identified at least on change within the 24 h period for 92% of patients. Most changes (90% n=1411) were medication-related, but the overall distribution of order types was significantly different between day and night (p=0.002). CONCLUSIONS AND RELEVANCE: The accuracy of printed handoff documents quickly deteriorated over the course of a physician shift. Based on this decay rate, a typical physician getting sign-out on 20 patients overnight can safely assume that the data for 10 of them will be inaccurate or outdated in 6 h and that it will be inaccurate on another two by the morning.

Not ready, not set discharge: Patient-reported barriers to discharge readiness at an academic medical center.

BACKGROUND: Planning for discharge from the hospital should begin early in each patient's stay and focus on the patient's needs. OBJECTIVE: To determine how often patient-reported barriers to discharge on admission were resolved by discharge and to explore associations between barriers and readmission. DESIGN, SETTING, AND PARTICIPANTS: A prospective observational study of patients admitted to an academic medical center. INTERVENTION AND MEASUREMENTS: Patients completed a barriers to discharge survey from the start of hospitalization to discharge. Primary outcomes were the prevalence of discharge barriers, rates of resolution of barriers during hospitalization, and comparisons between barriers identified in admission and discharge surveys. RESULTS: One hundred sixty-three patients were enrolled, and 68 patients (42%) completed an admission survey and discharge survey ≤48 hours before discharge. Patients completed on average 1.82 surveys (standard deviation, 1.10; range, 1-8). Total and mean numbers of barriers were highest on the admission survey and decreased until the fourth survey. On average, the total number of barriers to discharge decreased by 0.15 (95% confidence interval: 0.01-0.30) per day (P = 0.047). Ninety percent of patients were discharged with at least 1 issue. The 3 most common barriers on the admission and discharge survey remained the same: pain, lack of understanding of recovery plan, and daily-living activities. CONCLUSIONS: Patient-reported barriers to discharge are prevalent and incompletely addressed. This suggests an opportunity for improved discharge planning and a framework for communication between providers and patients. Journal of Hospital Medicine 2016;11:610-614. © 2016 Society of Hospital Medicine.

Using Tablet Computers to Increase Patient Engagement With Electronic Personal Health Records: Protocol For a Prospective, Randomized Interventional Study.

BACKGROUND: Inadequate patient engagement in care is a major barrier to successful transitions from the inpatient setting and can lead to preventable adverse events after discharge, particularly for older adults. While older adults may be less familiar with mobile devices and applications, they may benefit from focused bedside training to engage them in using their Personal Health Record (PHR). Mobile technologies such as tablet computers can be used in the hospital to help bridge this gap in experience by teaching older, hospitalized patients to actively manage their medication list through their PHR during hospitalization and continue to use their PHR for other post-discharge tasks such as scheduling follow-up appointments, viewing test results, and communicating with providers. Bridging this gap is especially important for older, hospitalized adults as they are at higher risk than younger populations for low engagement in transitions of care and poor outcomes such as readmission. Greater understanding of the advantages and limitations of mobile devices for older adults may be important for improving transitions of care. OBJECTIVE: To better understand the effective use of mobile technologies to improve transitions in care for hospitalized, older adults and leverage these technologies to improve inpatient and postdischarge care for older adults. METHODS: We will compare an intervention group with tablet-based training to engage effectively with their PHR to a control group also receiving tablets and basic access to their PHR but no additional training on how to engage with their PHR. RESULTS: Patient enrollment is ongoing. CONCLUSIONS: Through this grant, we will further develop our preliminary dataset and practical experience with these mobile technologies to catalyze patient engagement during hospitalization. CLINICALTRIAL: ClinicalTrials.gov NCT02109601; https://clinicaltrials.gov/ct2/show/NCT02109601 (Archived by WebCite at http://www.webcitation.org/6jpXjkwM8).

Tablet computers for hospitalized patients: a pilot study to improve inpatient engagement.

Inadequate patient engagement in hospital care inhibits high-quality care and successful transitions to home. Tablet computers may provide opportunities to engage patients, particularly during inactive times between provider visits, tests, and treatments, by providing interactive health education modules as well as access to their personal health record (PHR). We conducted a pilot project to explore inpatient satisfaction with bedside tablets and barriers to usability. Additionally, we evaluated use of these devices to deliver 2 specific Web-based programs: (1) an interactive video to improve inpatient education about hospital safety, and (2) PHR access to promote inpatient engagement in discharge planning. We enrolled 30 patients; 17 (60%) were aged 40 years or older, 17 (60%) were women, 17 (60%) owned smartphones, and 6 (22%) owned tablet computers. Twenty-seven (90%) reported high overall satisfaction with the device, and 26 (87%) required ≤ 30 minutes for basic orientation (70% required ≤ 15 minutes). Twenty-five (83%) independently completed an interactive educational module on hospital patient safety. Twenty-one (70%) accessed their personal health record (PHR) to view their medication list, verify scheduled appointments, or send a message to their primary care physician. Next steps include education on high-risk medications, assessment of discharge barriers, and training clinical staff (such as respiratory therapists, registered nurses, or nurse practitioners) to deliver tablet interventions.