Wednesday, April 18, 2012

Readmissions, iPad, and Patient Education

The latest ‘craze’ in healthcare, specifically in hospitals, is the problem surrounding unplanned readmissions. First, let’s start by laying the foundation. What exactly is an unplanned readmission?

Basically, it is exactly what it sounds like. A patient is discharged from the hospital and once they are home the patient’s condition deteriorates again and the patient is re-admitted to the hospital for either the same reason or related complications. So, why is this a big deal? Some assume that such readmissions are an indication that the patient’s discharge was not planned well enough and therefore the patient did not properly take care of themselves at home. 

It is assumed that such readmissions can be prevented. With that, Medicare is going to penalizing hospitals that have a high rate of readmissions.

In order to curtail readmissions many hospitals are strengthening the discharge process. In other words, they are taking pains to implement systems for follow up with patients post discharge to make sure that medications are filled and outpatient follow ups are performed. Some hospitals are even using a statistical method called LACE to calculate the probability that a patient will be a readmission.

The LACE calculation scores each patient based on historic information associated with past  (L) length of stays,  (A) acuity (level of care required in the past hospitalizations), (C) co-morbidity (other conditions that complicate the treatment of the primary condition for which the patient was admitted), and (E) emergency room visits in the past 6 months. When a patient has a high LACE score, the hospital staff takes extra precautions to ensure that post discharge instructions are followed in hopes of preventing a readmission.

Now, the big question… Will it work? Well, I agree that proper discharge planning is an important part of the picture. I also agree that there are some patients who need to be reminded to take care of themselves. Further, some patients are higher risk for readmission than others.  But, will these measures alone work? I don’t think they will resolve the problem because these measures are superficial. These measures fail to address the REAL problem. So, what’s the real problem? I will answer that with a story that I’ll bet is familiar to many people.

A couple of months ago, I took a relative to the emergency room. The doctor came and performed a 10 minute examination then left the room. There was no explanation, no information, nothing useful to understand what was wrong with the patient. Within a few minutes the patient was whisked off for a CT scan…. Of what, I don’t know. Then there was blood work. What was the blood work for? I don’t know. What were the results? I don’t know. Ultimately, the hospitalization was 3 days in observation and when my relative left we had ZERO answers… but, we had a discharge plan! For what??? We don’t know that either.

Now, don’t assume we were standing helpless waiting for info. We were asking – but the answers were either not forthcoming or so complicated that we’d need an MD to understand the jargon. A similar thing happened recently when I went with a friend to the doctor’s office. Time and time again, I hear this same story from patients. Doctors are too busy to explain in simple, but non patronizing terms to patients. That is the reason for readmissions. Patients do not understand their condition therefore they don’t understand how to take care of themselves post discharge. They assume that hospital discharge means that they are all better. What else would they assume when information is so limited?

I find it shocking that a patient can go into the hospital and leave less educated about their condition than they were on arrival. Further, people in the hospital are sick. When you are sick, you don’t think clearly, you are scared. A sick person needs things simplified and reinforced with reassurance and kindness. If hospitals were able to master this – readmissions would decrease with or without the LACE score.

One might suppose that since doctors and hospital staff are not easily changed, this is a hopeless situation. I, however, do not agree. I think technology is the answer and it is easily attainable with current technology….

Imaging this: Every hospital begins using an EMR software that contains all patient information – medications, conditions, lab results, physician’s orders, progress notes, acuity, bed assignment, etc.. So far, this is nothing earth shattering and certainly nothing that we don’t already see. But, imagine that this EMR also has a patient facing user interface that is super simple and displays in easy to understand terms every medications, orders, lab results, etc. associated with the individual patient's EMR record. 

The patient can have bedside access to a touch screen computer, like iPad, from which they can click on the condition name, medication name, order, etc. to watch a patient-friendly, short educational video explaining the item on which the patient clicked.  Since the videos are associated with the EMR record and the record is associated with the bed assignment, when the patient moves from bed to bed in the hospital, their patient education information moves with them as each hospital bed has a single monitor that only displays the record for the patient currently in that bed.

For example, if the patient is ordered to have a CT scan of the spine performed, clicking on CT scan of the spine in the orders list will link to educational information about a CT scan of the spine including what to expect and why it is performed. Each video must answer the most common questions as well as provide information to the patient that will prepare the patient for self-care post discharge.  For example, if the patient wants to learn about a medication, Coumadin perhaps, the educational video will explain the medication, why it is taken and explains that the patient must avoid certain foods high in Vitamin K, such as dark green leafy veggies, as well as to have regular blood tests to check the thickness of their blood.

The constant availability of information throughout the patient’s hospitalization and simplicity of the program will encourage patients to refer back to the system often for clarification facilitating reinforcement of the educational information. This reinforcement from the videos coupled with a means of education that caters to auditory learning, visual learning, and kinesthetic learning is a surefire way to help patients leave the hospital with a better understanding as well as improve their satisfaction with the hospital’s care. The availability of information will make for more confident patients and better discharge results because the patients have learned about their condition and the self-care required. When the patient is ready to be discharged, printed information can still be presented to the patient BUT it will have more meaning to the patient. For more tech savvy patients, continued access to the patient user interface (UI) described above with an integrated personal health record (PHR) post discharge will keep up the momentum at home. 

Sounds impossible or outrageously expensive, right? No, not really. We are half way there already. Mayo Clinic, for example, has started using iPad to provide patient education before heart surgery.  For the patient education information itself, RelayHealth has awesome Patient Education Digital Animations.

As you can see, the opportunity is out there and I really hope that it will become more commonly used in hospitals - sooner rather than later. Ultimately, we cannot really decrease readmissions until patients are more educated about their health, their conditions, and their responsibility at home post-discharge. That type of education needs to come from a source that is readily available, easy to use, caters to different learning styles, and offers constant reinforcement. 


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