using health it and patient engagement to improve patient ...€¦ · •randomized control trial:...
TRANSCRIPT
Using Health IT and Patient Engagement to
Improve Patient Outcomes
CenterforPatientSafety,Research,andPracticeBrighamandWomen’sHospitalPatriciaC.DykesPhD,RN,FAAN,FACMI
October2,2017
DisclosureStatement
• Thisprojectwassupportedbygrant#P30HS023535fromtheAgencyforHealthcareResearchandQuality(AHRQ).ThecontentissolelytheresponsibilityoftheauthorsanddoesnotnecessarilyrepresenttheofficialviewsofAHRQ.
Overview
• Background• Reviewcurrentstateofhealthcareteamcommunication
• Definepatientengagement
• DescribeaseriesofprojectsthatleveragehealthITtoimproveteamcommunication,patientengagement,andpatientsafety
• Reviewlessonslearned• Discussion
VanDenBos et.al.(2011)The$17.1 BillionProblem:TheAnnualCostOfMeasurableMedicalErrorsHealthAffairs.30(4)596-603.
First,DoNoHarm…
• Ineffectivecommunicationisaleadingrootcauseofmedicalerrors
TeamCommunicationChallenges
• Multiplehandoffs• Involvementofnumerousprofessionalandparaprofessionalproviders
• Variedcommunicationmethods• Simultaneousparallelconversations
• Informationsilos• Inconsistentbeliefsre:patient/familyroleoncareteam
TeamCommunicationisSuboptimal:BWHBaselineData
•AskedICUandOncologypatients(orcaregiver),bedsideRN,andphysicianfromprimaryteamaboutthepatient’soverallgoalforhospitalization
Category N=88 %
No.with1uniqueresponse 21 24%
No.with2uniqueresponse 44 50%
No.with3uniqueresponse 23 26%
No.(%)ofpatientswithXuniqueresponses
GoalsofCareamongHospitalizedPatients(Haberle 2011)
1. BeCured2. LiveLonger3. Improve&MaintainHealth4. BeComfortable5. Accomplishapersonallifegoal6. Providesupportforfamily7. Other
• “Providingcarethatisrespectfulofandresponsivetoindividualpatientpreferences,needs,andvalues,andensuringthatpatientvaluesguideallclinicaldecisions."
InstituteofMedicine,CrossingtheQualityChasm(2001)
Patient-centeredCare
PatientEngagement
Preconditionforpatient-centeredcare
PatientActivation Interventions/toolsdesignedtopromoteactivationandpositive
healthbehaviors
+
Hibbard & Green (2013). What The Evidence Shows About Patient Activation: Better Health Outcomes And Care Experiences; Fewer Data On Costs Health Affairs: 32 (2) 207-214
Activated,EngagedPatientsareMorelikelyto…
ü Engageinpreventivebehavior(check-ups,screenings,andimmunizations)
ü Engageinhealthybehaviorsuch(healthydiet,regularexercise)
ü Avoidhealth-damagingbehavior(smokingandillegaldruguse)
ü Incurlesscosts
BWHPROSPECTProjectPromotingRespectandOngoingSafetythroughPatientEngagementCommunicationandTechnology
• Goal:Totransformtheintensivecareenvironmentthroughimplementationofapatient-centeredinterventiontoengagepatientsandcarepartnersintheplanofcare
SupportedbytheMooreFoundation,DWBatesPI
PLAN OF CARE SAFETY DASHBOARD
Harry Potter Room 1040-A MRN: 1234567 DOB: 01/01/1990PlanofCareWorksheet
RoundsChecklist
PROVIDER MESSAGES
PATIENTMESSAGES
PATIENT LIST
NOTIFICATIONS
48-01 Granger, Hermione48-02 Dumbledore, Albus48-03 Potter, Harry
Harry Potter
Message Board
Conversation: Patti, Dr. Dumbledore, and Dr. Snape
New Message Contacts
SendSend
12:30PM
1:00 PM
12:33PM
I was reviewing my discharge checklist and think I may have trouble paying for some of the new medications that I am receiving now.
Harry, I will discuss during the meeting this afternoon.
Will my primary care doctor, Dr. Bates be available?
Yes, I will make every effort to join the meeting
Compose a message…You
Send
2
1
1
“Patient-facing”
Patient-CenteredToolKit(PCTK)Components
“Provider-facing”
ProviderFACINGTOOLSPROSPECT
SafetyChecklist
MultidisciplinaryPlanofCarePlatform
NursingPlanofCare
NursingPlanofCareDocumentation
PatientPlanofCareProblemsWithInfobuttons
PatientEducationalContent
ClinicalCareClassificationSystemProblemsandOutcomes
Patient-Centered‘Microblog’Functionality
PatientPortal:Patientsendsamessagetothecareteam.
ProviderPortal:Careteamcanviewandrespondusing‘patientthread’and‘providerthread’
PatientFACINGTOOLSPROSPECT
AttendingDr. Dalal
PCPDr. Bates
NurseP Dykes
MyCareTeam
• Improverespiratorystatus• Preventskinbreakdown• Freeofpain• Adequatenutrition
Becomfortable
Getoutofbed
Iwouldlikemysistertobeinvolvedinmycare
Becomfortable
Getoutofbed
Iwouldlikemysistertobeinvolvedinmycare
• Pain<4• Improveskinintegrity• Temp<100.5
MySafetyConcerns
MyMedications
Education&Training
PROSPECTResearchQuestionandStudyDesignDoesthePROSPECTframeworkpositivelyimpactsatisfaction,careplanconcordance,andleadtoreductioninadverseeventsandhealthcareresourceutilizationandcosts?
Data collection (control and intervention units)
Pre-implementationPeriod Post-implementationPeriod
Pre-PostDesign
PROSPECTIntervention
7/1/13– 6/8/14 7/1/14– 5/29/15
6/9/14– 6/30/14
Wash-in Period
PROSPECT Patient Demographics• Pre:1030• Post:1075• Demographicssimilarpre-post;PostpatientlesslikelytobeCaucasian(p=.02)
• Toolkitusers:194(18%)§ Meanage:60§ MorelikelytobeCaucasianandprivatepay
Findings
Pre-intervention
Intervention
P-value
Preventableharms/1000 patientdays 65.2 46.6 <.001
Overallhospitalrating(patient) 71.8% 93.3% <.001
Overallsatisfaction(carepartners) 84.3% 90.0% <.001
Meanglobalconcordanceoverallgoalofhospitalization
26.9% 34.0% <.001
Resourceutilization•Mean(Median)LengthofStay(days)•30-dayhospitalreadmission
4.9(2)19%
5.0(2)18.4%
0.610.82
Findings*
• Improvedpatient/carepartnersatisfaction
• Reductioninadverseevents• Nochangeincarepanconcordance
• Nochangeinresourceutilization
*DykesPC,RozenblumR,DalalA,MassaroA,ChangF,ClementsM,CollinsS,Donze J,FaganM,GazarianP,HannaJ,LehmannL,LeoneK,LipsitzS,McNallyK,MorrisonC,SamalL,Mlaver E,SchnockK,StadeD,WilliamsD,YoonC,BatesDW.ProspectiveEvaluationofaMultifacetedInterventiontoImproveOutcomesinIntensiveCare:ThePromotingRespectandOngoingSafetyThroughPatientEngagementCommunicationandTechnologyStudy.CriticalCareMedicine2017May03.PMID:28471886.
• PatientFeedback:• “It’sareallygreatidea.We’realwaysaskingquestionssothiswaywewon’thavetochaseanyonedown”
• (Inresponseto“MyCareTeampage)“Thesearemyfriends!I’veknownthemfor7years.It’snicetoseetheirpictureshere”
• “Withsomethinglikethis,youknowwhat’sgoingon”
• “Thisisgreat!Patientsneedmoreinfoaboutrisks,safety,medications,‘whoismydoctor’...”
PROSPECTTeam
BWHResearchInvestigators
• DavidBates– PrincipalInvestigator• SarahCollins– Co-Investigator/NursingInformaticsSpecialist
• AnujDalal– Co-Investigator• PatriciaDykes– Co-Investigator/Director• PriscillaGazarian– Co-Investigator• JohnHanna– ResearchAssistant• JaehoLee– GraphicalDesign• LisaLehmann– Co-Investigator• StuartLipsitz– Biostatistician• KellyMcNally– ResearchAssistant• EliMlaver– ResearchAssistant• ConnyMorrison– ResearchAssistant• KumikoOhashi– ProjectManager• SuchetaRavindran– ResearchAssistant• RonenRozenblum– Co-Investigator• LipikaSamal– Co-Investigator• DianaStade– ResearchAssistant• CathyYoon– DataAnalyst
ClinicalLeadership• Oncology
• TedAlyea–MedicalDirector• EddyChen–MedicalOncologist• KatieFillipon– NursingDirector• MarshaMalone– NursingDirector
• MICU• KathleenLeone– NursingDirector• AnthonyMassaro–MedicalDirector
OtherCollaborators• FrankChang – Developer• GeorgeGetty – Developer• DeborahWilliams– DatabaseProgrammer• MaureenFagan – ExecutiveDirectorforPatientsandFamilies
• CareThreadInc.
FallTIPS(TailoringInterventionsforPatientSafety)
FallTIPS(TailoringInterventionsforPatientSafety)
•2yearmixedmethodsstudyfundedbyRobertWoodJohnsonFoundation:
• Qualitativephase:• whydohospitalizedpatientsfall?• whatinterventionsareeffectiveandfeasibleinhospitalsettings?
• Randomizedcontroltrial:totestafallpreventiontoolkitdesignedtoaddressissuesidentifiedduringqualitativephase.
SupportedbytheRobertWoodJohnsonFoundation,DykesPI
32
TheFallTIPSToolkitRequirements
Fallriskassessment Tailoredplan
TheFallTIPSToolkit:FallRiskAssessment/TailoredPlan
35
Therewerefewerfallsininterventionunitsthanin
controlunits
Nosignificanteffectwasnotedinfallrelatedinjuries
• Findings:– Patientfallsweresignificantlyreducedon
interventionunits.
Patientsaged65orolderbenefitedmostfromtheFall
TIPStoolkit
FallPreventionLessonsLearned
Strategiesandtoolstofacilitatethe3-stepfallpreventionprocesswillpreventpatientsfromfalling!
FallPreventionLessonsLearned• FallTIPSreducedfallsby25%but>90%offallsarepreventable…whathappened?
• WhydidsomepatientswithaccesstotheFallTIPSToolkitfall?• Whatfactorsareassociatedwithfallsinyoungerpatients?• Whatfactorsareassociatedwithfallsinolderpatients?
• Secondaryanalysisoffallers(cases)n=48and144matchedcontrolsexposedtotheFallTIPStoolkit*
• Foundthatinallcases,plannedinterventionswerenotfollowedconsistentlybythepatient(mostfrequently)orthenurse
• i.e.,Outofbedwithassistance
HowdowegetpatientstoCONSISTENTLYfollowtheirfallpreventionplan?
DykesPC,I-ChingEH,SoukupJR,ChangF,LipsitzS.Acasecontrolstudytoimproveaccuracyofanelectronicfallpreventiontoolkit.AMIAAnnuSympProc.2012;2012:170-9.
RationaleforPatientEngagementin3-StepFallPreventionProcess
• Facilitatespatientunderstandingofpersonalfallriskstatusandtheplantopreventafall.
• Promotespatientunderstandingoftheirroleinfallprevention.• Facilitatespatient(andfamily)partnershipinensuringthattheplaniscarriedoutconsistently.
*DykesPC,I-ChingEH,SoukupJR,ChangF,LipsitzS.Acasecontrolstudytoimproveaccuracyofanelectronicfallpreventiontoolkit.AMIAAnnuSympProc.2012;2012:170-9.
Acommonreasonwhypatientsfallisthatplannedinterventionsarenotfollowedconsistentlybythepatient(mostfrequently)ortheteam*
BWHPatientSafetyLearningLabPatient-CenteredFallPreventionToolkit
PrimaryAim:
•Toengagepatientsandtheirfamilycaregiversaswellasprovidersinthedesignanddevelopmentofafallpreventiontoolkit.
ThisprojectwassupportedbygrantnumberP30HS023535fromtheAgencyforHealthcareResearchandQuality.ThecontentissolelytheresponsibilityoftheauthorsanddoesnotnecessarilyrepresenttheofficialviewsoftheAgencyforHealthcareResearchandQuality.
MixedMethods/ParticipatoryDesignApproach
• Surveys,observations,semi-structuredinterviews
• Nurses,patients,families• Interviewsrecorded,analyzedforthemes
• Focusend-userrequirementsforpatientparticipationin3-stepfallpreventionprocess
• Feedbackonprototypetools• Electronic• Paper
ProblemAnalysis
Design
Development
Implement
Evaluate
Iterative DesignandDevelopment
• Designphase§ PowerpointmockupsbySystemsEngineeringinternsat
NortheasternUniversity§ QualitativefeedbackfromPatientandFamilyAdvisory
Council(PFAC)andpatientsatbedside• Developmentphase
§ Systemandintegrationsoftwaretesting§ Usabilitytestingwithpatientsandproviderstorefinetools§ Iterativefallpreventionicondevelopmentwithongoing
patientandclinicianvalidation(patientn=90;cliniciansn=59)
Fall TIPS Electronic Tool Prototype
FALLRISKASSESSMENT EVIDENCE-BASEDFALLINTERVENTIONS
FallTIPSPaperToolPrototype
RequirementsforPatientEngagement
• Icons:Mustbepatientfriendly• Validatewithpatients
• Electronictool:Improvevisualappealofuserinterface,improveeaseofuse,eliminatedoublework/documentation
• Simplify• LinkwithMorseFallScale/fallpreventioninterventionsinEHR
• Papertool:Simplifyvisualdisplay,optimizeforusebypatient/family,• Adddecisionsupporttolinkareasofrisktointerventions• DevelopSpanishversion
Requirement:ValidateIconswithPatients
LeungWY,AdelmanJ,BatesDW,BusingerA,DykesJS,Ergai A,HurleyA,Katsulis Z,Khorasani S,ScanlanM,Schenkel L,RaiA,DykesPC.ValidatingFallPreventionIconstoSupportPatient-CenteredEducation.JPatientSafety.2017Feb22.PMID:28230576.
PatientName: Date:(Checkallthatapply) (Circleselectionbasedoncolor)
HistoryofFalls
MedicationSideEffects
WalkingAid
IVPoleorEquipment
UnsteadyWalk
MayForgetorChooseNottoCall
CommunicateRecentFalls
BedAlarmOn
IVAssistanceWhenWalking
UseAmbulatoryAid
Crutches Cane Walker
ToiletingSchedule:Every__hours
BedPan Commode
AssistanceOutofBed
None
Bathroom
Requirement:Simplify,adddecisionsupport,addSpanishversion
Fallriskassessment Tailoredplanbasedonpatient’sdeterminantsofrisk
LaminatedPaperFallT.I.P.S.
Usability Results: Fall TIPS Paper ToolSurvey Question Old (N=27) New (N=27) p-value
Mean Variance Mean Variance1. I think that I would like to use these tools frequently. 2.333 0.846 3.704 1.217 <.001
2. I find the tools unnecessarily complex. 3.148 1.746 1.667 1.077 <.0013. I think the tools are easy to use. 2.692 1.502 4.222 0.949 <.0014. I think that I would need the support of a fall prevention expert to be able to use these tools. 1.852 0.593 1.500 0.660 .112
5. I find the various functions in the tools are well-integrated. 2.593 0.866 3.852 1.131 <.001
6. I think there was too much inconsistency in available tools. 2.704 1.293 2.111 1.179 .06
7. I would imagine that most people would learn to use these tools very quickly. 2.889 1.333 4.296 1.063 <.001
8. I find the tools very cumbersome to use. 3.296 1.755 2.222 1.872 .0059. I felt very confident using these tools. 3.222 1.103 4.259 1.046 <.00110. I needed to learn a lot of things before I could get going with these tools. 2.423 1.134 1.852 0.823 .04
11. I am satisfied with the tools to support the fall prevention process at this hospital. 2.481 1.028 3.704 1.293 <.001
System Usability Scale, responses ranged from 1 (strongly disagree) to 5 (strongly agree).
Katsulis Z,Ergai A,LeungWY,Schenkel L,RaiA,AdelmanJ,BenneyanJ,BatesDW,DykesPC.Iterativeusercentereddesignfordevelopmentofapatient-centeredfallpreventiontoolkit.Appl Ergon.2016Sep;56:117-26.PMID:27184319.
FallTIPSPosterPilotTest
• January– June2016• Targetedunitswithfall/injuryratesabovehospitalandstatemean
Site/NumberofUnits
Service NumberofBeds
Brigham andWomen’sHospital/3 NeuroscienceIntermediateCare 43
Brigham andWomen’sHospital/2
MedicalIntermediateCare 31
Brigham andWomen’sHospital/2
Oncology 20
MontefioreMedicalCenter/1
MedicalIntermediateCare 36
FallTIPSPilotTestResults
0102030405060708090100
0.00
1.00
2.00
3.00
4.00
5.00
6.00
Percen
tofFallTIPScomplete
Fallspe
rtho
usan
dpa
tientdays
AverageFallRate2015vs.2016withAverageFallTIPSCompletion
2015
2016
AverageFallTIPSCompletion
Pre-interventionmeanfallrate:3.28
Post-interventionmeanfallrate:2.80
0102030405060708090100
0.00
0.50
1.00
1.50
2.00
2.50
Percen
tofFallTIPScomplete
Fallswith
injuryperth
ousand
patientdays
AverageFallRatewithInjury2015vs.2016withAverageFallTIPSCompletion
2015
2016
AverageFallTIPSCompletion
Pre-interventionmeanfallwithinjuryrate:1.00
Post-interventionmeanfallwithinjuryrate:0.54
FallTIPSAdherence:82%
Pre-FallTIPSFallRate:3.28
PostFallTIPSFallRate:2.80
Pre-FallTIPSInjuryRate:1.00
PostFallTIPSInjuryRate:.54
DykesPC,DuckworthM,CunninghamS,DuboisS,DriscollM,FelicianoZ,FerrazziM,FevrinF,LyonsS,LindrosM,MonahanA,PaleyM,Jean-PierreS,ScanlanM.PilotTestingFallTIPS(TailoringInterventionsforPatientSafety):aPatient-CenteredFallPreventionToolkit.TheJointCommissionJournalonQualityandPatientSafety.Aug2017
Patient-centered FallPreventionTools
• LaminatedpaperFallT.I.P.S.• Web-basedandmobilepatientportalstoaccessFallT.I.P.S.• PatientSafetyPlanScreensaverforallmembersofthecare
team,includingpatientsandfamily
PatientPortal(MobileApplicationview)–FallT.I.P.S.displayed
Patti’sPlanofCare
PatientPortal:FallTIPS
Patti’sPlanofCare
Patti’sPlanofCare
PatientRoomDesktopScreensaverPatientNeeds:Hearingaid,translator,glasses/contacts,latexallergy,armrestriction
SafetyReminders:Bradenscore,dietorder,catheterinfection,ulcer,restraints,PTexercisesetc
FallPrevention:Toiletingschedule,helptowalkwithIVPole,useambulatoryaidetc
Patti’sPlanofCare
LessonsLearned
• Multidisciplinaryinvolvementneededtoimproveclinicaloutcomes
• Clinicalchampionstoreinforcebestpractices
• Documentingreasonswhysafetychecklistitemsarenotindicated
• Patientcareunitsarebusy;manybarrierstoadoptionanduseofnewinnovations
• Patientslackcapacity,nocarepartner• Lackofaccessoutsideofhospital
• Adevicestrategyisneeded• Accessories• Storage• Cleaning• Security• Enrollment
• Patientswanttobeengagedbutstillchallenges
• Incapacitated,less“tech-savvy”,variably“activated”patients
• Accesstocontentfornon-Englishspeakingpatients
• Understandingofgoalsofcareconcept• Identifyingandprovidingaccesstocarepartnerscanaddresssomechallenges
• Moreworkneededre:• Workflowintegrationandclinicianbuy-in• Communicatingvalueofusingtechnology
Conclusions
•Makingcarebetter:₋ Willinvolvepartneringwithpatients.
₋ Willrequirehigh-techandlow-techsolutions
• Clinicianattitudesstillhaveawaystogo
₋ Willbehighlymultidisciplinary• Rolesofnursesandotherclinicianswillchange
•HealthITisopeningnewdoorsandweneedtotakeadvantage!
BrighamandWomen’sHospitalDavidBatesAlexBusingerSarahCollins
BrittanyCoutureAnujDalal
PatriciaDykesSarahKhorasaniLisaLehmannEmilyLeungStuartLipsitzEliMlaver
RonenRozenblumJeffreySchnipperKumikoSchnock
PartnersHealthCareFrankChang
RameshBapanapalliMohanBabuGanasekaranGennadyGorbovitsky
JamesBenneyanCoreyBalint
JenniferCoppolaNicholasFasanoZacharyKatsulis
MeredithClemmensLindseyBaldoAwatefErgai
DominicBreuerJillianHines
JessicaCleveland
ThankYou:BWH/NEUPatientSafetyLearningLabTeam
NortheasternInstituteofHealthcareSystemsEngineering
Patient-centeredFallPreventionPatriciaDykesEmilyLeungAwatefErgaiJillianHines
ZacharyKatsulisRameshBapanapalli
MohanBabuGanasekaranJasonAdelmanMaureenScanlan