Overview

Between December 2017 and July 2018, Brigham and Women’s Hospital (BWH),  an academic medical center, analyzed their implementation of digital health tools meant to reduce adverse events after discharge within three 30-bed general medicine units.

Organization Name

Brigham and Women’s Hospital (BWH)

Organization Type

• Academic Medical Center

Tech Involved

• Electronic medical record
• Text messaging
• Video

Team Members Involved

• Physicians
• RNs

Workflow Steps

• To alleviate adverse events post discharge, innovators at BWH created an interactive patient-centered discharge toolkit (PDTK). 
  • Components of the toolkit went through multiple iterations through the use of user-centered design principles. For example, a paper based copy of the checklist was created and tested on 10 patients and feedback was incorporated in real time. 
  •  This toolkit included a web-based video of the physician going through the steps of the checklist, a patient discharge readiness self-assessment checklist, and a secure text messaging system with the physician that was active up to seven days after discharge. These components were integrated into the EHR. 
  • To access the PDTK and complete its requirements, patients could either use their own cellphones or were given a hospital-issued mobile device.
• The checklist consisted of 16 questions under the following four domains: My Understanding, My Medications, My Self-Care Management, and My Follow-up. The discharge video simply walked the patient through each checklist domain 
• The PDTK was expected to be filled and submitted to the care team 24-48 hours prior to the expected discharge date (EDD).
  •  If a patient had not filled the checklist before the EDD, the physician would be notified. Every submission was available to the clinician within five minutes of submission.
•  English or Spanish speaking patients were eligible for the PDTK intervention. If a patient could not consent, a designated health care proxy was allowed to make the decision in lieu of the patient.

Outcomes

• Of the 752 patients enrolled in the study, 55.3% of participants watched the video and completed the checklist and an additional 12.5% completed the checklist alone. 
  • Those who did not submit a checklist were older, often Hispanic, non-English speaking, privately insured, and had longer lengths of stay 
•  The most commonly entered concerns were about medications  and follow up.
• Of all the checklists submitted by patients, 41.2% were viewed by clinical staff due to workflow challenges.
• A total of 33.4% of patients who filled out a checklist requested secure postdischarge  messaging with their provider but very few clinicians opted in.
• Twelve participants agreed to be interviewed about their experience and the two key takeaways from their interviews are:
  • Patients often felt left in the dark due to gaps in communication with their clinical care team prior to discharge.
  • In spite of the communication gaps, patients were confident that their care team would answer all their questions before being discharged.

Unique Challenges

• Low awareness/education: Most patients expected this intervention to improve communication about discharge between the physician and the patient. However, this did not happen due to poor buy in from physicians. This is attributed to a lack of physician awareness about the PDTK. Furthermore, many physicians did not know how to initiate secure messaging service and many were resistant to sign up for this service. 
• Optimization: When the checklist was submitted was paramount to its utility. If the checklist was submitted too early, its usefulness was not derived. If it is submitted too late, it gives physicians less time to prepare and address the concerns of the patient.

Sources

• Fuller TE, Pong DD, Piniella N, et al. Interactive Digital Health Tools to Engage Patients and Caregivers in Discharge Preparation: Implementation Study. J Med Internet Res. 2020;22(4):e15573. Published 2020 Apr 28. doi:10.2196/15573