After-visit Summaries Research Articles

Assessing the Impact of a Pharmacist-Managed Discharge Medication Reconciliation Pilot at a Community Hospital System.

With unintended medication discrepancy rates ranging from 30% to 70%, a formal discharge medication reconciliation process must be developed. One strategy shown to reduce medication errors is a pharmacist medication review at discharge. The purpose of this study is to determine the impact of a pharmacist-driven discharge medication reconciliation program. The intervention group included pharmacist-reviewed patients with a high risk of unplanned readmission score and had a discharge order signed during a 2-month period. The control group included eligible patients who were not reviewed by a pharmacist. The after-visit summaries for both groups were then reviewed for additional medication discrepancies. This study included 140 patients, with 70 patients in each group. A total of 176 discrepancies were identified in the intervention group and 235 were found in the control group. The median number of discrepancies per patient was not statistically different between groups (2 vs. 2, p-value = .196). There were 22 and 24 30-day hospital readmissions in the intervention and control groups, respectively (p-value = .857). More medication discrepancies were identified in the control group compared to pharmacist-reviewed patients. More robust studies including a pharmacist dedicated to discharge medication reconciliation should be conducted to identify the potential benefit.

Use and Usefulness of After-Visit Summaries by Language and Health Literacy among Latinx and Chinese Primary Care Patients

The after-visit summary (AVS), a document generated from the electronic health record that summarizes patients’ encounters with the healthcare system, is a widely used communication tool. Its use by and usefulness for populations with limited English proficiency (LEP) and limited health literacy (LHL) is poorly understood. In this cross-sectional study, we assessed use and usefulness of the AVS among English-, Spanish-, Cantonese-, or Mandarin-speaking Latinx and Chinese primary-care patients. Outcome measures were self-reported AVS use (did not use/looked-at only/shared only/looked-at and shared) and usefulness (useful/not useful). Among 993 participants, 57% were ≥65 years old, 61% had LEP, 21% had LHL, 30.2% were Latinx, 69.8% were Chinese. The majority used the AVS (86%) and found it useful (65%). In adjusted models, participants with LEP were more likely to “look at” (OR 1.68, 95% CI 1.07–2.62) and “look at and share” (OR 1.65, 1.02–2.66) the AVS, but less likely to find it useful (OR 0.68, 0.47–0.98) compared to English speakers. Those with LHL were less likely to “look at” (OR 0.60, 0.39–0.93) and less likely to find the AVS useful (OR 0.67, 0.46–0.99) compared to those with adequate health literacy. Our results emphasize the need for easy-to-understand and fully language-concordant AVS.

Impact of Age on Patients' Communication and Technology Preferences in the Era of Meaningful Use: Mixed Methods Study.

BackgroundIdentifying effective means of communication between patients and their health care providers has a positive impact on patients’ satisfaction, adherence, and health-related outcomes.ObjectiveThis study aimed to identify the impact of patients’ age on their communication and technology preferences when managing their health. We hypothesize that a patient’s age affects their communication and technology preferences when interacting with clinicians and managing their health.MethodsA mixed methods study was conducted to identify the preferences of patients with cardiovascular diseases. Results were analyzed based on the patients’ age. Grounded theory was used to analyze the qualitative data. Patients were recruited based on age, gender, ethnicity, and zip code.ResultsA total of 104 patients were recruited: 34 young adults (19-39 years), 33 middle aged (40-64), and 37 senior citizens (>65). Young adults (mean 8.29, SD 1.66) reported higher computer self-efficacy than middle-aged participants (mean 5.56, SD 3.43; P<.05) and senior citizens (mean 47.55, SD 31.23; P<.05). Qualitative analysis identified the following three themes: (1) patient engagement (young adults favored mobile technologies and text messaging, middle-aged patients preferred phone calls, and senior citizens preferred direct interactions with the health care provider); (2) patient safety (young adults preferred electronic after-visit summaries [AVS] and medication reconciliation over the internet; middle-aged patients preferred paper-based or emailed AVS and medication reconciliation in person; senior citizens preferred paper-based summaries and in-person medication reconciliation); (3) technology (young adults preferred smartphones and middle-aged patients and senior citizens preferred tablets or PCs). Middle-aged patients were more concerned about computer security than any other group. A unique finding among senior citizens was the desire for caregivers to have access to their personal health record (PHR).ConclusionsPatients of different ages have different communication and technology preferences and different preferences with respect to how they would like information presented to them and how they wish to interact with their provider. The PHR is one approach to improving patient engagement, but nontechnological options need to be sustained to support all patients.

The Efficacy of the After-visit Summary in Medication Recall Among Glaucoma Patients.

The purpose of this study was to determine whether patients given the AVS have better or worse glaucoma medication recall. Observational clinical study. Adults on ≥1 glaucoma medications examined between June 30, 2017 and August 2, 2017. in-person questionnaire and retrospective chart review. Self-reported glaucoma medications compared with prescribed glaucoma medication regimen verified by electronic medical record. Medication recall assessed using 3-point scoring: 1 point each for; (1) name or color of bottle or cap; (2) treatment eye(s); and (3) dosing regimen. 2-sample Welch t test, 2-proportion z-test, analysis of variance, univariate, and multivariate regression. A total of 118 patients enrolled: age 69.7±12.9 years (mean±SD), 55.9% of patients had received an AVS at the previous visit. Of these, 33.3% reported receiving an AVS, 51.2% reported not receiving one (15.1% did not recall or respond). Patients who had received AVSs had lower medication recall scores than those who did not (2.4±1.0 vs. 2.7±0.6, P=0.04). Receipt of an AVS was associated with having Nisha Chadha as their provider (P=0.01), fewer days since prior visit (P=0.0001), and medication regimen change at prior visit (P<0.0001). Multivariate analysis revealed completion of associate's degree or higher and fewer prescribed medications to be independent predictors of higher recall score (P=0.0002 and 0.002). AVSs were conceived to enhance patient care. This study indicates this goal is not achieved consistently. Less education and more complex medication regimens were identified as barriers to medication recall. Additional investigations should explore if modifying this document and enhanced explanation of its use will impact medication recall and health outcomes.

COVID-19-A Guide to Rapid Implementation of Telehealth Services: A Playbook for the Pediatric Gastroenterologist.

COVID-19-A Guide to Rapid Implementation of Telehealth Services: A Playbook for the Pediatric Gastroenterologist.

Patient-Reported Use of the After Visit Summary in a Primary Care Internal Medicine Practice.

Participants completed a cross-sectional survey about their use of the after visit summary (AVS) at a previous primary care visit. Of 355 participants, 294 (82.8%) recalled receiving it, 67.4% consulted it, 45.9% consulted it more than once, and 31.6% shared the AVS. In multivariable analysis, higher education and older age were associated with AVS consultation. Among the subset of 133 patients recalling personalized free-text instructions, 96% found them easy to understand and 94.4% found them useful. Our findings suggest that the AVS is a useful communication tool and improvement efforts should emphasize clarity for those most vulnerable to communication errors.

What can we do about Dr. Google? Using the electronic medical record (EMR) to prescribe reliable online patient education

ObjectiveThe project enabled clinicians to utilize the electronic medical record (EMR) to easily prescribe preapproved online patient education resources to their patients.BackgroundPhysicians and other clinicians are concerned about the wide use of “Dr. Google” and the difficulties of responding to patients who demand unproven or unnecessary tests and therapies they found out about on the Internet.Setting/Participants/ResourcesParticipants were providers at a large health system using Epic EMR. The institution maintains a web-based database that links to print and electronic patient education materials that have been vetted by content experts.MethodsClinicians worked with librarians to create web pages that link to the resources they recommend for their patients. Librarians collaborated with the information technology (IT) department to implement a solution that enables clinicians to quickly and easily send the uniform resource locator (URL) to the after visit summary (AVS) or as a message via the patient portal.ResultsThis solution has been implemented in more than 20 units across the institution. Analytics data demonstrate that the majority of patients in a surgery clinic visited recommended resources.ConclusionThis simple solution is effective in directing patients to reliable resources. It can be easily adapted by other institutions using an EMR system such as EPIC or Cerner.

After Visit Summary: Not an Afterthought

The After Visit Summary (AVS) is provided to patients after clinical visits to summarize what happened during the visit and guide future care. Despite its potential to improve shared decision-making, self-management, and communication, the design of the typical AVS is not optimized to communicate useful information in an understandable way. The AVS usability challenge is magnified in vulnerable patient populations such as those served by community health centers (CHCs). The purpose of this research was to evaluate and refine a redesigned AVS intended to better communicate information to CHC patients.

Abstract No. 576 Standardizing after-visit summary instructions to improve patient satisfaction scores

Abstract No. 576 Standardizing after-visit summary instructions to improve patient satisfaction scores

Team-based care: an expanded medical assistant role – enhanced rooming and visit assistance

ABSTRACT Primary care practices face significant challenges as they pursue the Quadruple Aim. Redistributing care across the interprofessional primary care team by expanding the role of the medical assistant (MA) is a potential strategy to address these challenges. Two sequential, linked processes to expand the role of the MA, called Enhanced Rooming and Visit Assistance, were implemented in four family medicine residency clinics in Minnesota. In Enhanced Rooming, MAs addressed preventive services, obtained a preliminary visit agenda, and completed a warm hand-off to the provider. In Visit Assistance, MAs stayed in the room the entire visit to assist with the visit workflow. Enhanced Rooming and Visit Assistance processes were successfully implemented and sustained for over one year. MAs and providers were satisfied with both processes, and patients accepted the expanded MA roles. Mammogram ordering rates increased from 10% to 25% (p < 0.0001). After Visit Summary (AVS) print rates increased by 12% (p < 0.0001). Visit Turn-Around-Time (TAT) decreased 3.1 minutes per visit (p = 0.0001). Expanding the MA role in a primary care interprofessional team is feasible and a potentially useful tool to address the Quadruple Aim.

Yonder: Patient complaints, after-visit summaries, rectal bleeding, and the doorknob phenomenon.

Yonder: Patient complaints, after-visit summaries, rectal bleeding, and the doorknob phenomenon.

Challenges optimizing the after visit summary

BackgroundThe after visit summary (AVS) is a paper or electronic document given to patients after a medical appointment, which is intended to summarize patients’ health and guide future care, including self-management tasks. ObjectiveTo describe experiences of health systems implementing a redesigned outpatient AVS in commercially available electronic health record (EHR) systems to inform future optimization. Materials and MethodsWe conducted semi-structured interviews with information technology and clinical leaders at 12 hospital and community-based healthcare institutions across the continental United States focusing on the process of AVS redesign and implementation. We also report our experience implementing a redesigned AVS in the Epic EHR at the Mount Sinai Hospital in New York City, NY. ResultsHealth systems experienced many challenges implementing the redesigned AVS. While many IT leaders noted that the redesigned AVS is easier to understand and the document is better organized, they claim the effort is time-consuming, Epic system upgrades render AVS modifications non-functional, and primary care and specialty practices have different needs in regards to content and formatting. Our team was able to modify the document by changing the order of print groups, modifying the font size, bolding section headers, and inserting page breaks. Similar to other health systems, our team found that it is difficult to achieve some desired features due to limitations in the EHR platform. ConclusionHealth IT leaders view the AVS as a valuable source of information for patients. However, limitations to AVS modifications in EHR systems present challenges to optimizing the tool. EHR vendors should incorporate learning from healthcare systems innovation efforts and consider building more flexibility into their product development.

Electronic Order Volume as a Meaningful Component in Estimating Patient Complexity and Resident Physician Workload.

Though patient census has been used to describe resident physician workload, this fails to account for variations in patient complexity. Changes in clinical orders captured through electronic health records may provide a complementary window into workload. We aimed to determine whether electronic order volume correlated with measures of patient complexity and whether higher order volume was associated with quality metrics. In this retrospective study of admissions to the internal medicine teaching service of an academic medical center in a 13-month period, we tested the relationship between electronic order volume and patient level of care and severity of illness category. We used multivariable logistic regression to examine the association between daily team orders and two discharge-related quality metrics (receipt of a high-quality patient after-visit summary (AVS) and timely discharge summary), adjusted for team census, patient severity of illness, and patient demographics. Our study included 5,032 inpatient admissions for whom 929,153 orders were entered. Mean daily order volume was significantly higher for patients in the intensive care unit than in step-down units and general medical wards (40 vs. 24 vs. 19, P < .001). Order volume was also significantly correlated with severity of illness (P < .001). Patients were 12% less likely to receive a timely discharge summary for every 100 additional team orders placed on the day prior to discharge (OR 0.88; 95% CI 0.82-0.95). Electronic order volume is significantly associated with patient complexity and may provide valuable additional information in measuring resident physician workload.

A Heuristic Evaluation to Assess Use of After Visit Summaries for Supporting Continuity of Care.

Outpatient providers often do not receive discharge summaries from acute care providers prior to follow-up visits. These outpatient providers may use the after-visit summaries (AVS) that are given to patients to obtain clinical information. It is unclear how effectively AVS support care coordination between clinicians. Goals for this effort include: (1) developing usability heuristics that may be applied both for assessment and to guide generation of medical documents in general, (2) conducting a heuristic evaluation to assess the use of AVS for communication between clinicians, and (3) providing recommendations for generating AVS that effectively support both patient/caregiver use and care coordination. We created a 17-item heuristic evaluation instrument for assessing usability of medical documents. Eight experts used the instrument to assess each of four simulated AVS. The simulations were created using examples from two hospitals and two pediatric patient cases developed by the National Institute of Standards and Technology. Experts identified 224 unique usability problems ranging in severity from mild to catastrophic. Content issues (e.g., missing medical history, marital status of a 2-year-old) were rated as most severe, but widespread formatting and structural problems (e.g., inconsistent indentation, fonts, and headings; confusing ordering of information) were so distracting that they significantly reduced readers' ability to efficiently use the documents. Overall, issues in the AVS from Hospital 2 were more severe than those in the AVS from Hospital 1. The new instrument allowed for quick, inexpensive evaluations of AVS. Usability issues such as unnecessary information, poor organization, missing information, and inconsistent formatting make it hard for patients, caregivers, and clinicians to use the AVS. The heuristics in the new instrument may be used as guidance to adapt electronic health record systems so that they generate more useful and usable medical documents.

After-visit summaries in primary care: mixed methods results from a literature review and stakeholder interviews

After-visit summary (AVS) documents presenting key information from each medical encounter have become standard in the USA due to federal health care reform. Little is known about how they are used or whether they improve patient care. First, we completed a literature review and described the totality of the literature on AVS by article type and major outcome measures. Next, we used reputational sampling from large-scale US studies on primary care to identify and interview nine stakeholders on their perceptions of AVS across high-performing primary care practices. Interviews were transcribed and coded for AVS use in practice, perceptions of the best/worst features and recommendations for improving AVS utility in routine care. The literature review resulted in 17 studies; patients reported higher perceived value of AVS compared with providers, despite poor recall of specific AVS content and varied post-visit use. In key informant interviews, key informants expressed enthusiasm for the potential of using AVS to reinforce key information with patients, especially if AVS were customizable. Despite this potential, key informants found that AVS included incorrect information and did not feel that patients or their practices were using AVS to enhance care. There is a gap between the potential of AVS and how providers and patients are using it in routine care. Suggestions for improved use of AVS include increasing customization, establishing care team responsibilities and workflows and ensuring patients with communication barriers have dedicated support to review AVS during visits.

Development of a web-based toolkit to support improvement of care coordination in primary care.

Promising practices for the coordination of chronic care exist, but how to select and share these practices to support quality improvement within a healthcare system is uncertain. This study describes an approach for selecting high-quality tools for an online care coordination toolkit to be used in Veterans Health Administration (VA) primary care practices. We evaluated tools in three steps: (1) an initial screening to identify tools relevant to care coordination in VA primary care, (2) a two-clinician expert review process assessing tool characteristics (e.g. frequency of problem addressed, linkage to patients' experience of care, effect on practice workflow, and sustainability with existing resources) and assigning each tool a summary rating, and (3) semi-structured interviews with VA patients and frontline clinicians and staff. Of 300 potentially relevant tools identified by searching online resources, 65, 38, and 18 remained after steps one, two and three, respectively. The 18 tools cover five topics: managing referrals to specialty care, medication management, patient after-visit summary, patient activation materials, agenda setting, patient pre-visit packet, and provider contact information for patients. The final toolkit provides access to the 18 tools, as well as detailed information about tools' expected benefits, and resources required for tool implementation. Future care coordination efforts can benefit from systematically reviewing available tools to identify those that are high quality and relevant.

599 Bringing therapeutic patient education in atopic dermatitis into the 21st century: A novel, low-cost, personalized, electronic health record-based framework

The term “therapeutic patient education” (TPE) refers to teaching by healthcare practicioners that is designed to help patients and families manage chronic disease and improve quality of life. TPE improves treatment adherance, reduces complications, reduces overall cost of care and improves survival in congestive heart failure, diabetes mellitus and rheumatoid arthritis, among other diseases. Stalder et al and other groups have described implementation of TPE for atopic dermatitis (AD). Widespread implementation of TPE programs for AD has been limited by issues of cost, limited time during a clinic visit, and patient willingness to attend educational sessions outside the clinic visit. To address these difficulties, we developed a novel framework for TPE centered on the after-visit summary (AVS) in the EpicTM electronic health record (EHR) and applied it to a cohort of approximately 400 pediatric atopic dermatitis patients seen by 20 pediatricians. Our objective was to personalize the educational materials without increasing provider work-burden or adding substantial cost to AD care. A cubic regression of fingertip units (FTU) of topical ointment or cream needed to cover 100% of the body at any given age was generated based upon published data, as well as a quartic regression of FTU of topical ointment or cream needed to cover 100% of the face at any given age. Assessment of body surface area involved and patient age allows an EHR script to be generated with recommended quantity of topical agent to be utilized, which is incorporated into printed patient handout materials. Patients’ perceived control over their disease, knowledge of treatments and self-efficacy are being measured at baseline and followup. This project is currently ongoing; patient pools for pediatricians have been identified and all TPE materials have been written and coded. TPE materials developed from existing clinical practice guidelines will be presented.

Delivery of Standardized Patient Instructions in the After-Visit Summary Reduces Telephone Calls Between Clinic Visits.

Telephone calls from patients can be a large source of between-visit work in outpatient clinics. A baseline audit at the study clinic identified medication refills and test results as the most common preventable calls. The authors created a dot phrase with standardized text detailing methods for refilling medications and reviewing test results and instructed providers to use it in the after-visit summary (AVS). After implementation of the AVS dot phrase, telephone calls for medications and results had an adjusted absolute decrease of 23.9 (95% CI = 15.4-32.4) calls per day to 16.2 (SD 7.7) calls per day, a relative reduction of 61%. Providers reported significantly fewer inbox requests for both refills ( P = .04) and test results ( P = .01). Using a standardized AVS dot phrase to inform patients on how to navigate care needs can significantly reduce between-visit workload for clinic staff and providers.

Evaluation of a patient-centered after visit summary in primary care

ObjectiveTo test the impact of a redesigned, patient-centered after visit summary (AVS) on patients’ and clinicians’ ratings of and experience with the document. MethodsWe conducted a difference-in-differences (DiD) evaluation of the impact of the redesigned AVS before and after its introduction in an academic primary care practice compared to a concurrent control practice. Outcomes included ratings of the features of the AVS. ResultsThe intervention site had 118 and 98 patients in the pre- and post-intervention periods and the control site had 99 and 105, respectively. In adjusted DiD analysis, introduction of the patient-centered AVS in the intervention site increased patient reports that the AVS was an effective reminder for taking medications (p = .004) and of receipt of the AVS from clinicians (p = .002). However, they were more likely to perceive it as too long (p = .04). There were no significant changes in overall rating of the AVS by clinicians or their likelihood of providing it to patients. ConclusionsA patient-centered AVS increased the number of patients receiving it and reporting that it would help them remember to take their medications. Practice implicationsImprovements in the patient-centeredness of the AVS may improve its usefulness as a document to support self-management in primary care.

Promoting Documentation of Suicidality in a Family Medicine Residency Clinic.

Careful assessment of depression and suicidality are important given their prevalence and consequences for quality of life. Our study evaluated the impact of an educational intervention in a family medicine residency clinic on rates of provider documentation regarding suicidality. We offered two brief workshops to our clinic staff and created two standardized charting templates to empower and educate providers. One template used with the patient during the clinic visit elicited key factors (eg, plan, intent, barriers) and offered treatment plan options. The second template included supportive text and resources to include in the after-visit summary. A chart review was completed, examining 350 patient records in which the patient reported thoughts of death or suicide in the preceding 2 weeks on the Patient Health Questionnaire-9 ([PHQ-9], 150 over a 5-month baseline period, 150 in months 1 through 4 immediately following the workshops and template development, and 50 at follow-up months 7 through 8 following the intervention). We examined use of the templates and changes in rates of documentation of suicidality. Rates of provider documentation of suicidality for patients who had expressed suicidal ideation on the PHQ-9 increased significantly from 57% at baseline to 78% in the postintervention phase; the rise persisted at follow-up. Rates of use of the assessment template were 58% (postintervention) and 49% (follow-up). Anecdotal provider feedback reflected appreciation of the templates for assessing and documenting challenging issues. Brief educational interventions were associated with improved rates of provider documentation of suicidality. The longer-term impact of the workshops and templates warrant further investigation.