Do Combined Pharmacist and Prescriber Efforts on Medication Reconciliation Reduce Postdischarge Patient Emergency Department Visits and Hospital Readmissions?

BACKGROUND: Although medication reconciliation (Med Rec) has demonstrated a reduction in potential adverse drug events, its effect on hospital readmissions remains inconclusive. OBJECTIVE: To evaluate the impact of an interprofessional Med Rec bundle from admission to discharge on patient emergency department visits and hospital readmissions (hospital visits). METHODS: The design was a retrospective, cohort study. Patients discharged from general internal medicine over a 57-month interval were identified through administrative databases. Patients who received an enhanced, Gold level, Med Rec bundle (including both admission Med Rec and interprofessional pharmacist-prescriber collaboration on discharge Med Rec) were assigned to the intervention group. Patients who received partial Med Rec services, Silver and Bronze level, comprised the control group. The primary outcome was hospital visits within 30 days of discharge. RESULTS: Over a 57-month period, 9931 unique patient visits (n = 8678 patients) met the study criteria. The main analysis did not detect a difference in 30-day hospital visits between the intervention (Gold level bundle) and control (21.25% vs 19.26%; adjusted odds ratio, 1.06; 95% confidence interval [CI], 0.95-1.19). Propensity score adjustment also did not detect an effect (16.7% vs18.9%; relative risk of readmission, 0.88; 95% CI, 0.59-1.32). CONCLUSION: A long-term, observational evaluation of interprofessional Med Rec did not detect a difference in 30- day postdischarge patient hospital visits between patients who received enhanced versus partial Med Rec patient care bundles. In future prospective studies, researchers could focus on evaluating high-risk populations and specific elements of Med Rec services on avoidable, medication-related hospital admissions and postdischarge adverse drug events.

A Review on the Quality of Colonoscopy Reporting.

Colonoscopy reports are important communication tools for providers and patients with potential to serve as information sources for research, quality, performance, and resource management. Despite decades of work, studies continue to indicate that colonoscopy reports are often incomplete. Although electronic medical records (EMRs) and databases can address this problem, costs, workflow, and interoperability (difficulty exchanging information between systems) continue to limit adoption and implementation of endoscopy EMRs in Canada and elsewhere. Quality and reporting guidelines alone have proven to be insufficient. In this review we have derived and applied five key themes to challenges in the current state of colonoscopy reporting and propose strategies to address them.

Discrepancy between gastroenterologists' and general surgeons' perspectives on repeat endoscopy in colorectal cancer.

BACKGROUND: A myriad of localization options are available to endoscopists for colorectal cancer (CRC); however, little is known about the use of such techniques and their relation to repeat endoscopy before CRC surgery. We examined the localization practices of gastroenterologists and compared their perceptions toward repeat endoscopy to those of general surgeons. METHODS: We distributed a survey to practising gastroenterologists through a provincial repository. Univariate analysis was performed using the χ² test. RESULTS: Gastroenterologists (n = 69) reported using anatomical landmarks (91.3%), tattooing (82.6%) and image capture (73.9%) for tumour localization. The majority said they would tattoo lesions that could not be removed by colonoscopy (91.3%), high-risk polyps (95.7%) and large lesions (84.1%). They were equally likely to tattoo lesions planned for laparoscopic (91.3%) or open (88.4%) resection. Rectal lesions were less likely to be tattooed (20.3%) than left-sided (89.9%) or right-sided (85.5%) lesions. Only 1.4% agreed that repeat endoscopy is the standard of care, whereas 38.9% (n = 68) of general surgeons agreed (p < 0.001). General surgeons were more likely to agree that an incomplete initial colonoscopy was an indication for repeat endoscopy (p = 0.040). Further, 56% of general surgeons indicated that the findings of repeat endoscopy often lead to changes in the operative plan. CONCLUSION: Discrepancies exist between gastroenterologists and general surgeons with regards to perceptions toward repeat endoscopy and its indications. This is especially significant given that repeat endoscopy often leads to change in surgical management. Further research is needed to formulate practice recommendations that guide the use of repeat endoscopy, tattoo localization and quality reporting.

CONTEXTE: De nombreuses options de repérage s'offrent aux endoscopistes dans les cas de cancer colorectal; on en sait cependant peu sur l'utilisation de ces techniques et leur lien avec les endoscopies répétées avant les interventions chirurgicales de traitement de ce cancer. Nous avons étudié les pratiques de repérage employées par des gastroentérologues et comparé leurs perceptions des endoscopies répétées à celles des chirurgiens généralistes. MÉTHODES: Nous avons réalisé un sondage auprès de gastroentérologues en exercice figurant dans un répertoire provincial. Une analyse unidimensionnelle a été effectuée à l'aide du test χ². RÉSULTATS: Les gastroentérologues (n = 69) ont dit recourir à des repères anatomiques (91,3 %), au tatouage (82,6 %) et à des images (73,9 %) pour repérer les tumeurs. La majorité a dit tatouer les lésions ne pouvant être éliminées par coloscopie (91,3 %), les polypes à haut risque (95,7 %) et les lésions de grande taille (84,1 %). Ils étaient tout aussi susceptibles de tatouer les lésions devant être éliminées par résection laparoscopique (91,3 %) ou effractive (88,4 %). Ils étaient cependant moins susceptibles de tatouer les lésions rectales (20,3 %) que les lésions du côté gauche (89,9 %) ou du côté droit (85,5 %). Seul 1,4 % des gastroentérologues était d'avis que l'endoscopie répétée constitue une norme en matière de soins, contrairement à 38,9 % des chirurgiens généralistes (n = 68; p < 0,001). Les chirurgiens généralistes étaient plus nombreux à penser qu'une coloscopie initiale incomplète était susceptible d'être associée à des endoscopies répétées (p = 0,040). En outre, 56 % d'entre eux ont indiqué que les résultats d'endoscopies répétées menaient souvent à des changements sur le plan chirurgical. CONCLUSION: Il existe des divergences entre les perceptions des gastroentérologues et des chirurgiens généralistes quant aux endoscopies répétées et à leur indication. Ces divergences sont particulièrement pertinentes, étant donné que les endoscopies répétées entraînent souvent des changements aux interventions chirurgicales qui sont pratiquées ultérieurement. Des recherches approfondies seront nécessaires pour formuler des recommandations liées aux pratiques et orienter le recours aux endoscopies répétées et au repérage des lésions par tatouage ainsi que la production de rapports sur la qualité.

Smartphones and Patient Care: Exploring the Use of Text-Based Messaging for Patient-Related Communication.

Background Text messaging (texting) has become a routine medium of communication in society. However, its use among clinicians has not been fully characterized. We explored general surgery residents' practices and views on texting for patient-related communication. Methods An email survey was distributed to all general surgery residents at a large Canadian medical school. Results Overall, 46 (57%) of those surveyed responded. All used texting for patient-related communication. Eleven percent of residents did not have a password on their cell phone and 89% did not have encrypted phones. Texting was the most common way (41%) by which residents communicated routine patient-related information with staff physicians. Most (85%) residents agreed that texting enhances patient care. The majority (66%) did not know if their hospital had a policy on texting and were unaware of legislation surrounding texting in patient care (89%). Conclusions Most general surgery residents use texting for communication of routine patient-related care issues. However, they acknowledge concerns regarding the security of this medium.

It's not about pager replacement: an in-depth look at the interprofessional nature of communication in healthcare.

BACKGROUND: Institutions have tried to replace the use of numeric pagers for clinical communication by implementing health information technology (HIT) solutions. However, failing to account for the sociotechnical aspects of HIT or the interplay of technology with existing clinical workflow, culture, and social interactions may create other unintended consequences. OBJECTIVE: To evaluate a Web-based messaging system that allows asynchronous communication between health providers and identify the unintended consequences associated with implementing such technology. DESIGN: Intervention-a Web-based messaging system at the University Health Network to replace numeric paging practices in May 2010. The system facilitated clinical communication on the medical wards for coordinating patient care. Study design-pre-post mixed methods utilizing both quantitative and qualitative measures. PARTICIPANTS: Five residents, 8 nurses, 2 pharmacists, and 2 social workers were interviewed. Pre-post interruption-15 residents from 5 clinical teams in both periods. MEASUREMENTS: The study compared the type of messages sent to physicians before and after implementation of the Web-based messaging system; a constant comparative analysis of semistructured interviews was used to generate key themes related to unintended consequences. RESULTS: Interruptions increased 233%, from 3 pages received per resident per day pre-implementation to 10 messages received per resident per day post-implementation. Key themes relating to unintended consequences that emerged from the interviews included increase in interruptions, accountability, and tactics to improve personal productivity. CONCLUSIONS: Meaningful improvements in clinical communication can occur but require more than just replacing pagers. Introducing HIT without addressing the sociotechnical aspects of HIT that underlie clinical communication can lead to unintended consequences.

Order sets in health care: a systematic review of their effects.

OBJECTIVES: Order sets are widely used in hospitals to enter diagnosis and treatment orders. To determine the effectiveness of order sets in improving guideline adherence, treatment outcomes, processes of care, efficiency, and cost, we conducted a systematic review of the literature. METHODS: A comprehensive literature search was performed in various databases for studies published between January 1, 1990, and April 18, 2009. A total of eighteen studies met inclusion criteria. No randomized controlled trials were found. RESULTS: Outcomes of the included studies were summarized qualitatively due to variations in study population, intervention type, and outcome measures. There were no important inconsistencies between the results reported by studies involving different types of order sets. While the studies generally suggested positive outcomes, they were typically of low quality, with simple before-after designs and other methodological limitations. CONCLUSIONS: The benefits of order sets remain eminently plausible, but given the paucity of high quality evidence, further investigations to formally evaluate the effectiveness of order sets would be highly valuable.

Effect of home blood pressure telemonitoring with self-care support on uncontrolled systolic hypertension in diabetics.

Lowering blood pressure reduces cardiovascular risk, yet hypertension is poorly controlled in diabetic patients. In a pilot study we demonstrated that a home blood pressure telemonitoring system, which provided self-care messages on the smartphone of hypertensive diabetic patients immediately after each reading, improved blood pressure control. Messages were based on care paths defined by running averages of transmitted readings. The present study tests the system's effectiveness in a randomized, controlled trial in diabetic patients with uncontrolled systolic hypertension. Of 244 subjects screened for eligibility, 110 (45%) were randomly allocated to the intervention (n = 55) or control (n = 55) group, and 105 (95.5%) completed the 1-year outcome visit. In the intention-to-treat analysis, mean daytime ambulatory systolic blood pressure, the primary end point, decreased significantly only in the intervention group by 9.1 ± 15.6 mmHg (SD; P < 0.0001), and the mean between-group difference was 7.1 ± 2.3 mmHg (SE; P < 0.005). Furthermore, 51% of intervention subjects achieved the guideline recommended target of <130/80 mmHg compared with 31% of control subjects (P < 0.05). These improvements were obtained without the use of more or different antihypertensive medications or additional clinic visits to physicians. Providing self-care support did not affect anxiety but worsened depression on the Hospital Anxiety and Depression Scale (baseline, 4.1 ± 3.76; exit, 5.2 ± 4.30; P = 0.014). This study demonstrated that home blood pressure telemonitoring combined with automated self-care support reduced the blood pressure of diabetic patients with uncontrolled systolic hypertension and improved hypertension control. Home blood pressure monitoring alone had no effect on blood pressure. Promoting patient self-care may have negative psychological effects.

Real-time automated paging and decision support for critical laboratory abnormalities.

BACKGROUND: For patients with critical laboratory abnormalities, timely clinical alerts with decision support could improve management and reduce adverse events. METHODS: The authors developed a real-time clinical alerting system for critical laboratory abnormalities. The system sent alerts to physicians as text messages to a smartphone or alphanumeric pager. Decision support was available via smartphone or hospital intranet. The authors evaluated the system in a prospective controlled stepped-wedge study with blinded outcome assessment in general internal medicine units at two academic hospitals. The outcomes were the proportion of potential clinical actions that were actually completed in response to the alert, and adverse events (worsening of condition or complications related to treatment of the condition). RESULTS: The authors evaluated 498 laboratory conditions on 271 patients. Overall, only 50% of potential clinical actions were carried out, and there were adverse clinical events within 48 h for 36% of the laboratory conditions. The median (IQR) proportion of potential clinical actions that were actually completed was 50% (33-75%) with alerting system on and 50% (33-100%) with alerting system off (p=0.94, Wilcoxon rank sum test). When the alerting system was on (n=164 alerts) there were 67 adverse events within 48 h of the alerts (42%). When the alerting system was off (n=334 alerts), there were 112 adverse events within 48 h (33%; difference: 9% higher with alerting system on, p=0.06). CONCLUSIONS: The provision of real-time clinical alerts and decision support for critical laboratory abnormalities did not improve clinical management or decrease adverse events.

The impact of telemedicine on greenhouse gas emissions at an academic health science center in Canada.

OBJECTIVE: This study estimates the reduction in greenhouse gas (GHG) emissions resulting from 840 telemedicine consultations completed in a 6-month time period. Our model considers GHG emissions for both vehicle and videoconferencing unit energy use. Cost avoidance factors are also discussed. MATERIALS AND METHODS: Travel distances in kilometers were calculated for each appointment using postal code data and Google Maps™ Web-based map calculator tools. RESULTS: Including return travel, an estimated 757,234 km were avoided, resulting in a GHG emissions savings of 185,159 kg (185 metric tons) of carbon dioxide equivalents in vehicle emissions. Approximately 360,444 g of other air pollutant emissions was also avoided. The GHG emissions produced by energy consumption for videoconference units were estimated to be 42 kg of carbon dioxide equivalents emitted for this sample. CONCLUSIONS: The overall GHG emissions associated with videoconferencing unit energy is minor when compared with those avoided from vehicle use. In addition to improved patient-centered care and cost savings, environmental benefits provide additional incentives for the adoption of telemedicine services.

Patient perceptions of remote monitoring for nocturnal home hemodialysis.

Adoption of nocturnal home hemodialysis (NHHD) has been slow, due in part to patient-perceived barriers, such as anxiety and lack of self-efficacy. This study investigates patient perception of remote monitoring in addressing these barriers. Perceptions of remote patient monitoring (RPM) were studied through a quantitative survey and qualitative interviews. The NHHD and conventional hemodialysis (CHD) were included in the survey (209 in total). Twenty semistructured interviews were conducted as well as a focus group that included NHHD patients and family caregivers. The CHD patients had greater interest in adopting NHHD with RPM than without (1.90±1.37 vs. 1.71±1.28, P<0.002), with the negative intensity ratio declining from 10.50 to 5.56. Interest in RPM was correlated with interest in NHHD (r=0.768, P<0.001). Other significant factors correlated with interest in NHHD include the belief that remote monitoring will ease the performing of NHHD (r=0.452, P=0.001) and the belief that RPM should be mandatory (r=0.541, P=0.000). Qualitative findings supported three themes: (1) There is an expectation for the use of RPM, (2) RPM should be used at a minimum transitionally, and (3) RPM acts as a surrogate support of family-caregivers. The RPM may lower perceived barriers to the adoption of NHHD, in part through its surrogate support of family caregivers. However, RPM alone is likely insufficient to alter patients' attitudes to undergo NHHD. RPM is a common expectation of CHD patients considering the therapy, at a minimum during the transitional phase.

The use of smartphones for clinical communication on internal medicine wards.

BACKGROUND: Communication between clinicians is hampered by the frequent difficulty in reaching the most responsible physician for a patient as well as the use of outdated methods such as numeric paging. The aim of this study was to evaluate the use of smartphones to improve communication on internal medicine wards. METHOD: At the Toronto General Hospital, residents were provided with smartphones. To simplify reaching the most responsible resident for a patient, a smartphone designated as "Team BlackBerry" was also carried by each senior resident and then passed to the resident covering the team at night and on weekends. Nurses were able to send email messages or call smartphones directly. RESULTS: There were on average of 9.1 incoming calls, 6.6 outgoing calls, 14.3 received emails, and 2.8 sent emails per day to each Team BlackBerry. Team BlackBerrys received up to 35 calls and 57 emails per day. Residents strongly preferred the smartphones over conventional paging with perceived improvements in all items measured and felt that it improved efficiency and communication. Although nurses perceived a reduction in the time required to contact a physician (27.6 vs. 11 minutes P < 0.001), their overall satisfaction with physician's response time for urgent issues did not improve significantly. DISCUSSION: When smartphones were used for clinical communication, residents perceived an improvement in communication with them. Residents strongly preferred emails as opposed to telephone calls as the prime method of communication. Further objective evaluation is necessary to determine if this intervention improves efficiency and more importantly, quality of care.

Effectiveness of asynchronous tele-endoscopy.

BACKGROUND: Asynchronous tele-endoscopy can improve access and quality of patient care. This is the first published evaluation of the diagnostic accuracy of highly compressed digital video in GI endoscopy. OBJECTIVE: To determine whether asynchronous tele-endoscopy using highly compressed video can accurately document and diagnose lesions in the upper GI tract. DESIGN: Local endoscopists performed 50 elective upper GI endoscopies. A high-quality DV compressed video (25 megabits per second [Mbps], 720 x 480 pixels) and highly compressed MPEG-1 video (2.0 Mbps, 352 x 240 pixels) were simultaneously captured. Five endoscopists asynchronously reviewed 20 compressed digital videos (100 case reviews) for endoscopic diagnoses. In addition, demonstration technique and image quality were rated on a Likert scale. Concordance between local and asynchronous endoscopists for major and minor endoscopic findings was evaluated. An independent panel classified discrepancies as caused by image quality, endoscopic technique, or interobserver variability through comparison of the 2 forms of digital video. RESULTS: Although asynchronous endoscopists rated the image quality of highly compressed video as diagnostic in 85% of cases, only 18% of studies yielded the same clinical diagnoses. There was high discordance for both major (kappa = 0.38, 95% CI, 0.19-0.57) and minor findings (kappa = -0.29, 95% CI, -0.43 to -0.15). Interobserver reporting was responsible for 90% of variability in contrast to only 4.9% for poor image quality. CONCLUSIONS: The findings suggest that the diagnostic accuracy of low-bandwidth, low-resolution, highly compressed video is well tolerated and comparable to the current standard. Interobserver reporting variability accounted for most of the poor correlation. Improved synoptic documentation is required for effective communication among endoscopists.

Human factors perspectives on a systemic approach to ensuring a safer medication delivery process.

The current, prevailing approach to addressing medication delivery safety issues has been to apply solutions at the point of failure with direct, local remediation. These include computerized physician order entry to address transcription and prescribing problems, tall man lettering for label clarity and smart pump systems to address programming use errors. We discuss the lack of a systemic, holistic approach to addressing medication delivery issues that has led to fragmented solutions that do not address the problem as intended and introduce new, unintended patient safety issues. We use recent case studies in addition to our own experimental data from human factors investigations to show how a comprehensive human factors approach can be applied to address systemic error in medication delivery. Only by identifying how (1) subsystems interconnect, (2) information flows, (3) care providers communicate and (4) users are impacted will healthcare organizations and system vendors be able to fully address error in medication delivery. Much of what is required from organizations is to transcend the organizational boundaries of medicine, pharmacy and nursing to produce a delivery system that ensures an integrated approach that addresses all stakeholders' needs.

Patient-perceived barriers to the adoption of nocturnal home hemodialysis.

BACKGROUND AND OBJECTIVES: Nocturnal home hemodialysis (NHHD) has been shown to improve clinical outcomes, although adoption has been limited. Given the known benefits, an understanding of the barriers to adoption is needed. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Patient-perceived barriers were studied through a cross-sectional survey of prevalent hemodialysis patients using validated instruments, study-specific questions, and ethnographic interviews. Fifty-six of 66 NHHD patients and 153 of 199 conventional hemodialysis (CHD) patients were included in the survey. Twenty interviews were conducted with NHHD, CHD, and predialysis patients. RESULTS: Compared with CHD patients, NHHD patients had higher perceived physical health scores (Short Form 12 [SF-12]: 41.47 +/- 10.9 versus 34.73 +/- 10.6, P < 0.0001), but had similar mental health scores (47.30 +/- 11.1[NHHD] versus 45.27 +/- 11.3[CHD]), P = 0.25). Despite having similar measures of education and perceived social support as NHHD patients, CHD patients had a low interest (1.68 [out of 5] +/- 1.26) in adopting NHHD. The major barriers perceived by CHD patients were lack of self-efficacy in performing the therapy, lack of confidence in self-cannulation, and length of time on current therapy. Similar themes emerged from the qualitative analysis as well as: burden on family members and fear of a catastrophic event. CONCLUSIONS: Patient-perceived barriers are primarily fears of self-cannulation, a catastrophic event, and the burden on family. These findings should form the basis of screening patients for interest in NHHD and serve to mitigate these concerns.

The user-centered approach in the development of a complex hospital-at-home intervention.

We discuss the development of a comprehensive remote patient monitoring system that facilitates the self-care of patients undergoing nocturnal home hemodialysis (NHHD), a complex hospital-at-home therapy. The use of a continuous, iterative approach with user involvement for the validation of assumptions can avoid situations where the system serves a patient poorly. An ethnographic analysis was used to determine specific design principles, which were reviewed with the patients prior to development of the system. Iterative designs were tested through usability testing and further validation was done with a member-checking exercise. Patients expressed concern about the physical obtrusiveness of monitoring which, consequently, led to a lack of adherence. The need for monitoring the integrity of the bloodlines was identified as important because one of the most significant fears among patients was potential blood loss. Patients expressed a need for immediate human intervention in response to an alert. The use of ethnography, usability testing, and member-checking methods in a user-centered approach to design can result in systems that better meet the needs of the patients and caregivers alike.

Demonstrating the BlackBerry as a clinical communication tool: a pilot study conducted through the Centre for Innovation in Complex Care.

Canadians are living longer with chronic medical conditions, which have led to an increasing complexity and volume of care for hospitalized patients. Effective in-patient care depends on the effective coordination of care through rapid and efficient communication between various care providers. A delay in coordinating this care has downstream effects on other parts of the system, ultimately contributing to increased emergency department wait times. To address this system-wide issue, the Centre for Innovation in Complex Care at the University Health Network collaborated with Sunnybrook Health Sciences Centre to pilot the use of BlackBerry devices on the general internal medicine wards to improve clinical communication. We describe the implementation process, impact on clinical care and lessons learned from this experience. We observed that residents quickly adopted this new technology and felt that it improved their workflow efficiency and productivity.

A mobile phone based remote patient monitoring system for chronic disease management.

Rising concern over the poor state of chronic disease management led to the user-informed design and development of a home tele-monitoring system. Focus groups with patients and primary care providers guided the research team towards a design that would accommodate the workflow and concerns of the healthcare providers and the low use and comfort with technology found among the patient population. The system was trialed in a before-and-after pilot study of 34 patients with diabetes and hypertension. Findings demonstrate a significant improvement in systolic and diastolic blood pressure. An RCT beginning in 2007 is being conducted to confirm these findings. It is hypothesized that this user-centred approach, utilizing focus groups, iterative design and human factors methods of evaluation, will lead to the next-generation of home tele-monitoring applications that are more intuitive, less cumbersome, and ultimately bring about greater patient compliance and better physician management.

Telemanagement of hypertension: a qualitative assessment of patient and physician preferences.

BACKGROUND: Prevalence surveys have consistently found that the blood pressure control rate among people with hypertension is less than 25%. Studies of telemedicine as a means of providing care to hypertensive patients have shown that this approach is effective in lowering blood pressure. Major design flaws and high operating costs, however, have hindered its adoption by physicians and patients. OBJECTIVES: In the present commentary, the field of telemedicine, as it pertains to hypertension management, is reviewed, and the investigators' experiences in developing a new telemedicine system are outlined. METHODS: An applied qualitative case study approach was used to determine the information needs for the design of a telemedicine system. Opinions were elicited separately from type 2 diabetic patients with hypertension (n=24) and family practitioners in active clinical practice (n=18). RESULTS: Physician and patient focus group meetings provided key information that led to changes in the prototype system. The low level of computer and Internet use by patients in everyday life and by physicians in practice-related activities precluded their inclusion in the design of the system for information retrieval and receiving clinical alerts. For patients, the mobile phone appeared to be an acceptable alternative. The only practical, automated means to disseminate reports and alerts to physicians was by fax, which was the most universally available device in a doctor's office. CONCLUSION: This tightly focused qualitative study led to the development of design principles for a prototype system, increasing the likelihood of user acceptance and improving its effectiveness.