using health it and patient engagement to improve patient ...€¦ · •randomized control trial:...

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.(%)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

using health it and patient engagement to improve patient ...€¦ · •randomized control trial:...

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