Pre-discharge education might not seem like the kind of activity that would attract fans, but at Boston Medical Center (BMC), there's one health care provider whose instruction on medication regimens and other aspects of post-discharge care is preferred by patients.
Her name is Louise, and she's a computer program. Louise, whose official title is “virtual patient advocate,” was developed as part of BMC's Project RED, an initiative to re-engineer discharge (RED) to improve patient safety and reduce readmissions.
The overall project has lowered hospital utilization by recently discharged patients about 30%, and Louise has contributed to that improvement, as well as boosted patient satisfaction. “At the end of the interaction, we ask, ‘Who would you rather receive discharge instructions from—a doctor or a nurse or Louise?’ and twice as many say Louise,” said Brian Jack, MD, associate professor of family medicine at Boston University School of Medicine/BMC and developer of Project RED. “It's because Louise has plenty of time. Doctors and nurses are always in a hurry.”
Clinicians' limited time is a major reason why computerized patient education programs might become a fixture of hospitals of the future.
Already, Louise is not alone. At the University of Pittsburgh Medical Center (UPMC), online software is being used to educate patients before surgery, and that's only the beginning, according to Thomas Worrall, MD, medical director of the UPMC Center for Quality Improvement and Innovation. “We're on the tip of the iceberg in trying to develop tools like this that help physicians and patients come together and manage their diseases and understand their procedures,” he said.
At BMC, Louise grew out of clinicians' awareness that patients didn't understand as much as they should, and that their lack of knowledge could lead to readmissions. “It was clear that people being discharged didn't really understand what they were supposed to do in order to take care of themselves,” said Dr. Jack. “We knew if we could use health information technology to teach patients, that would save nurses' time and thereby help hospitals to implement important patient safety interventions.”
Louise does necessitate some nursing time. Her program requires information about all of a patient's medications, follow-up appointments, upcoming tests and tests with pending results. Depending on a hospital's existing computer system, that information may need to be input by nurses, or it could flow automatically from the electronic medical record. The nurse then prints out the after-hospital care plan, a large-print, colorful booklet designed to be patient-friendly.
The booklet and the kiosk containing Louise are brought to the patient's bed. “If they say, ‘I've never used a computer before,’ which a lot do, we train our staff to say, ‘Give us one minute and if after one minute you don't want to use it, you don't have to.’ Then the nurse will push the button and Louise comes on and calls them by name, and says ‘How are you doing?’ and on the touch screen are the responses,” explained Dr. Jack.
The nurse encourages the patient to respond, and then Louise goes through the after-hospital plan with the patient. “Nobody has ever said they can't do it after one minute, no matter what the age,” said Dr. Jack.
The program also tests patients on their understanding of the material. “After she teaches the medication, she'll say, ‘OK, can you tell me how you're going to take your lisinopril?” said Dr. Jack. If the patient, who can look up the correct response in the after-hospital plan, gets an answer wrong, Louise goes back and reviews the information.
“The competency testing we have found to be very important,” said Dr. Jack. It's also an aspect of teaching that the physicians or nurses who would usually provide this education may not have time to do, he added.
A randomized controlled trial of Louise is currently underway, and early results are indicating that the program reduces hospital utilization (readmission and emergency visits) in patients with low health literacy, Dr. Jack reported.
If the benefits are confirmed, the program could spread to other hospitals relatively easily. “That's the beauty of it,” said Dr. Jack. “With a software program, if we can set it up so it can be done easily by the nurses on the floor, then the scalability is even greater than it would be training people one by one.”
Another method of virtually educating patients has already been implemented in hospitals in various parts of the country. Emmi Solutions, a company started in 2002, has created an online software program that educates patients before medical procedures.
When a patient is scheduled to undergo a hip replacement, for example, or even just a colonoscopy, his or her physician can provide the Web address and login information for the relevant Emmi program.
Patients who log in are educated about steps to be taken pre-operatively and about post-op care, as well as how the procedure works and potential risks, benefits and alternatives. “It doesn't replace the face-to-face conversation between the patient and the physician, but it surely augments it to a great extent,” said Dr. Worrall.
The program asks patients to confirm their understanding of the information and input any questions, then logs the entire interaction. It's become a part of UPMC's process of establishing informed consent. “It's difficult sometimes in a paper world to actually verify or validate the informed consent procedure, meaning the conversation between the physician and the patient and the patient's family. A tool where the patient's participation is actually measured and recorded—that they have viewed the information that you have provided—is a big aid in verifying,” said Dr. Worrall.
Like Louise, Emmi was designed to work for patients with limited computer skills. “All anyone really needs is Internet access somewhere, whether it's at their physician office, at home, at work, or at the hospital in the pre-op area,” said Devin Gross, chief executive officer of Emmi Solutions. “When we were developing the programs and the user interface, we said it had to be as easy as using your television remote control.”
Emmi's research on the use of the technology has shown that it appeals to almost all ages. “We don't see significant differences in adoption or utilization between the ages of 20 and 80 years old,” said Mr. Gross. Patients over 80 have been somewhat less likely to log into the software, but some hospitals are using the program most often for over-65-year-olds, he added.
As Dr. Worrall noted, the program doesn't replace physician-patient conversations about procedures, but it can change the content of those discussions to better use physicians' time. “Clinicians are really happy when they can focus on what I call the $100 questions. They like talking about unique clinical issues and what's specific to that patient. It's the $10 rote, repeatable questions that aren't the most valuable use of their time,” said Mr. Gross.
UPMC also found another, somewhat unexpected, benefit. Patients who viewed the educational program had a significantly lower length of stay; they left the hospital 0.7 of a day sooner. “Patients are more aware of the expectations of the post-operative course and they are more ready to travel the road to recovery than those that have no knowledge of what's going to happen next. They are geared up to start physical therapy on the first day or even the day of surgery,” said Dr. Worrall. “Their expectations are realistic and they are on board.”
Having patients on board with the plan of care may become even more important as payers move toward payment systems that reward hospitals for preventing readmissions.
“Reimbursement is more and more being tied to not the volume of care and the efficiency of care, but also the quality of care and what outcome you're able to deliver,” said Mr. Gross. “The incentives are going to drive [computer-based patient education] to catch on.”
While they wait for the new technology to catch on, both BMC and Emmi are expanding the reach of their programs. “We have a general program for how to give a medication history that allows patients to really understand the role they play in the medication reconciliation process. We have a whole series of programs that help patients manage a chronic condition—asthma, diabetes, hypertension, COPD,” said Mr. Gross.
Meanwhile, Louise is moving into patients' homes. Testing is underway on a program that allows recently discharged patients to log in and continue their conversation with her. “She'll say, ‘Are you taking these medications?’ If they say no, she'll say, ‘How come? Was it that you couldn't get to the pharmacy, couldn't afford it’…a whole bunch of reasons,” explained Dr. Jack.
Louise will also check to see whether patients are having any adverse reactions to their new medications, and then alert nurses back at the hospital to any issues. “Our data show that half the people when they go home from the hospital are doing something that's not quite right. We're hoping the at-home Louise system will be able to impact post-hospital problems,” said Dr. Jack. “If it reduces rehospitalizations, it will save significant amounts. There are not too many things that show improvement in care and cost less.”