Virtual Continuity and its Impact on Complex Hospitalized Patients' Care (Pennsylvania)

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Summary:

Communication between physicians of hospitalized patients and their primary care providers (PCPs) is often suboptimal. Hospital-based information systems can improve communication by automating information transfer between these two groups. This project enhanced MedTrak, the information system used by the University of Pittsburgh Medical Center (UPMC), with an intervention called Virtual Continuity. As initially envisioned, Virtual Continuity would provide automated real-time notification and alerts for patients undergoing transitions in care and allow PCPs to obtain current electronic medical records (EMR) and communicate with hospital physicians from a remote location.

The specific aims of this project were to:

  • Augment the present system of PCP notification through the development and use of electronic EMR links to allow Virtual Continuity for the PCP. 
  • Measure differences in patient care safety and quality between PCPs receiving Virtual Continuity versus usual communication in a pre-post study. 
  • Evaluate the impact of Virtual Continuity. 

The project used an expert panel of PCPs to inform the development of communication tools. A questionnaire was developed based on candidate items from the published literature on hospital and PCP communication, communication on medication changes made during hospitalizations, and post-hospitalization care planning.

A two-round modified Delphi survey with the experts was conducted via the Internet. This process showed that PCPs have definite preferences about the type of information they receive and when they receive it, which was not previously well characterized. They also wanted concise information about key findings, medication reconciliation, and followup plans, at the start and finish of hospital stays. PCPs were interested in receiving information about their patients’ emergency department (ED) visits—an area where present systems are frequently inadequate.

Following implementation of the tools, a pre- post-intervention study was conducted utilizing data from the EMR to evaluate the primary outcome of discharge medication errors, and on the secondary outcomes of 30-day rates of re-hospitalization, ED visits, and PCP followup visits. There was a statistically significant decrease in medication errors even when adjusted for age, sex, and the modified Elixhauser comorbidity index score. However, errors that were considered clinically significant—those leading to death, permanent or temporary disability, prolonged hospital stay, readmission, or the need for additional treatment or monitoring to protect the patient from harm—were rare and not significantly different between groups. There was no significant difference seen in PCP followup visits and ED visits at 30 days, or in 30-day readmission or death rates.

The pre-post study took the place of a planned randomized controlled trial, and thus the impact of Virtual Continuity, the third specific aim, was not able to be evaluated. The project succeeded in identifying PCP preferences for needed communication tools and demonstrating that discharge medication errors, the study’s primary outcome, were significantly decreased by a set of automated communication tools designed to update PCPs on their hospitalized patients who were under the care of a hospital physician.

Virtual Continuity and its Impact on Complex Hospitalized Patients’ Care - 2012

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    PAR: HS08-270: Utilizing Health Information Technology to Improve Health Care Quality Grant (R18)
  • Grant Number: 
    R18 HS 018151
  • Project Period: 
    October 2009 – January 2013
  • AHRQ Funding Amount: 
    $1,193,052
  • PDF Version: 
    (PDF, 250.76 KB)

Summary: Hospital care processes have changed dramatically over the last 10-to-15 years. Previously, hospitalized patients were cared for by their primary care physicians (PCPs), facilitating continuity of care between inpatient and ambulatory care settings. Currently, many hospitalized patients are cared for by hospital staff physicians and returned to PCPs’ care upon discharge. Without dedicated information transfer processes, this stratification of care can lead to information loss and medical error. Heightened communication with and involvement by the PCP in the care of hospitalized patients should decrease medication, diagnostic, and followup errors, thereby improving medical care quality and safety as well as patient and physician satisfaction.

This project enhanced MedTrak, the University of Pittsburgh Medical Center’s electronic physician communication tool, with an intervention called Virtual Continuity. Virtual Continuity allowed PCPs to follow their hospitalized patients electronically and participate more directly in their care through the use of emails that are triggered by clinical events. These emails were embedded with links to electronic medical record (EMR) data and communication portals, medication lists delivered at the time of admission and discharge, and immediate notification of discharge with pertinent clinical details.

A pre-post study compared the frequency of discharge medication errors before and after initiation of the Virtual Continuity intervention. Additional evaluation measures included PCPs’ frequency and timeliness of receiving information; PCPs’ perception of information exchange adequacy and usefulness; patients’ satisfaction with care and the information they received; rates of rehospitalization; post-discharge emergency department visits; and PCP followup visits. The costs of implementing and maintaining the
Virtual Continuity intervention were also assessed.

Specific Aims:

  • Augment the present system of PCP notification through the development and use of electronic EMR links to allow Virtual Continuity for the PCP. (Achieved)
  • Measure differences in patient care safety and quality between PCPs receiving Virtual Continuity versus usual communication in a pre-post study. (Achieved)

2012 Activities: Project activities focused on final analysis and development of a manuscript for submission to a peer reviewed publication. The project ended in January 2013.

Preliminary Impact and Findings: In Round 1 of the Delphi survey, 41.6 percent or 37 of 89 items were accepted by consensus and one was rejected. Of the 51 remaining items included in the Round 2 survey, six were accepted by consensus. At the start of the hospital stay, experts wanted emergency department visit data, including physician documentation, laboratory, and radiology results; medications; notification of admitting diagnoses; and consultants’ evaluation data. Primary care physicians wanted a brief description of the hospital course, discharge medication and medication reconciliation data, key hospitalization findings, a list of pending tests and their eventual results, and followup plans.

Differences in medication errors remained statistically significant on multivariable analysis adjusting for age, sex, and a comorbidity index score. Differences between PCP followup visits and emergency department visits at 30 days were no longer significant after adjustment. No significant differences were seen between groups in clinically important medication errors or in 30-day readmission or mortality rates. Statistically significant decreases in medication errors, in both unadjusted and adjusted analyses, were demonstrated when comparing the pre- and post-intervention periods. Clinically significant medication errors were rare and not significantly different between groups. Thirty-day patient outcomes were not significantly different between groups after adjustment. The absence of a randomized trial precluded any consideration of comparing differences in PCPs experiences with and without the intervention, and the retrospective nature of the pre-intervention data collection precluded any comparison of PCP experience pre- and post-intervention.

Target Population: Adults

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Knowledge Creation

Virtual Continuity and its Impact on Complex Hospitalized Patients' Care - 2011

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    PAR: HS08-270: Utilizing Health Information Technology to Improve Health Care Quality Grant (R18)
  • Grant Number: 
    R18 HS 018151
  • Project Period: 
    October 2009 - September 2012
  • AHRQ Funding Amount: 
    $1,193,052
  • PDF Version: 
    (PDF, 176.86 KB)

Summary: Hospital care processes have changed dramatically over the last 10-to-15 years. Previously, hospitalized patients were cared for by their primary care physician (PCP), facilitating continuity of care between inpatient and ambulatory care settings. Currently, many hospitalized patients are cared for by hospital staff physicians and returned to their PCPs' care upon discharge. Without dedicated information transfer processes, this stratification of care can lead to information loss and medical error. Heightened communication with and involvement by the PCP in the care of hospitalized patients should decrease medication, diagnostic, and followup errors, thereby improving medical care quality and safety as well as patient and physician satisfaction.

This project enhanced MedTrak, the University of Pittsburgh Medical Center's electronic physician communication tool, with an intervention called Virtual Continuity. Virtual Continuity allowed PCPs to follow their hospitalized patients electronically and participate more directly in their care through the use of e-mails that are triggered by clinical events with embedded links to electronic medical record (EMR) data and communication portals, medication lists electronically delivered at admission and discharge, and immediate notification of discharge with pertinent clinical details.

To evaluate the impact of Virtual Continuity, a pre-post study will compare the frequency of discharge medication errors before and after initiation of the Virtual Continuity intervention. Additional evaluation measures include PCPs' frequency and timeliness of receiving information, PCPs' perception of information exchange adequacy and usefulness, patients' satisfaction with care and the information they receive, rates of rehospitalization, post-discharge emergency department visits, and PCP followup visits. The information technology cost of implementing and maintaining the Virtual Continuity intervention will also be assessed.

Specific Aims:

  • Augment the present system of PCP notification through the development and use of electronic EMR links to allow Virtual Continuity for the PCP. (Achieved)
  • Measure differences in patient care safety and quality between PCPs receiving Virtual Continuity versus usual communication in a pre-post study. (Ongoing)
  • Evaluate the impact of Virtual Continuity. (Retired)

2011 Activities: The research team conducted a Delphi PCP survey via a Web-based interface. Data collection and analysis on the pre- and post-intervention period represented the majority of project work. Previous changes in study design, where the project is now collecting pre-intervention data via the EMR, have made it infeasible to collect survey data from this group, since informed consent, required for this data to be collected and linked to clinical data, cannot be obtained. In addition, the number of patients from whom they are able to obtain consent in the post-intervention phase continues to be well below their projections. The absence of pre-post data for comparisons and low numbers of surveys overall make evaluating the impact of Virtual Continuity difficult to achieve.

As last self-reported in the AHRQ Research Reporting System, project progress and activities are somewhat on track and the project budget funds are somewhat underspent. The original plan to evaluate the impact of Virtual Continuity was to measure PCP and patient satisfaction pre- and post- intervention. Pre-intervention study data being collected by the EMR have made it infeasible to collect survey data from this group because informed consent is required for this data to be collected and linked to clinical data. In addition, the number of patients from whom they were able to obtain consent in the post-intervention phase was well below their projections. Therefore, this aim was retired because the absence of pre-post data for comparisons and low numbers of surveys overall made it unlikely that it could be achieved.

Preliminary Impact and Findings: The Delphi survey results were completed. Rated items in the first round with a 95 percent confidence interval lower boundary of 4.0 or more were defined as accepted by the panel. Items with a 95 percent confidence interval upper boundary less than 3.0 were rejected. All other items were defined as indeterminate. In the second round of the survey, the panel was asked to reconsider those indeterminate data items, showing them their prior rating and the group mean for each item in an effort reach further consensus on those items.

In the first round of the Delphi survey, 37 of 89 items were accepted, one was rejected, and 51 were indeterminate. The second round survey considered these 51 indeterminate items and consensus to accept was reached for six more items.

Target Population: Adults

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Knowledge Creation

Virtual Continuity and its Impact on Complex Hospitalized Patients' Care - 2010

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    PAR: HS08-270: Utilizing Health Information Technology to Improve Health Care Quality Grant (R18)
  • Grant Number: 
    R18 HS 018151
  • Project Period: 
    October 2009 – September 2012
  • AHRQ Funding Amount: 
    $1,193,052
  • PDF Version: 
    (PDF, 352.28 KB)


Target Population: Adults

Summary: Hospital care processes have changed dramatically over the last 10 to 15 years. Previously, hospitalized patients were cared for by their primary care physician (PCP), facilitating continuity of care between inpatient and ambulatory care settings. Now, many hospitalized patients are cared for by hospital staff physicians and are returned to their PCPs’ care upon discharge. Without dedicated information transfer processes, this stratification of care can lead to information loss and medical error. Heightened communication with and involvement by the PCP in the care of hospitalized patients should decrease medication errors, diagnostic errors, and follow up errors, thereby improving medical care quality and safety as well as patient and physician satisfaction.

This project, started in October 2009, will enhance MedTrak, the University of Pittsburgh Medical Center (UPMC) electronic physician communication tool, with an initiative called Virtual Continuity. Virtual Continuity allows PCPs to follow their hospitalized patients electronically and participate more directly in their care through the use of e-mails that are triggered by clinical events with embedded links to electronic medical record (EMR) data and communication portals, medication lists electronically delivered at admission and discharge, and immediate notification of discharge with pertinent clinical details. The project is using the Cerner PowerChart EMR system, a Certification Commission for Health Information Technology-certified product.

To evaluate the impact of Virtual Continuity, a pre-post study will compare the frequency of discharge medication errors before and after initiation of the Virtual Continuity intervention. Additional evaluation measures include PCPs’ frequency and timeliness of receiving information, PCPs’ perception of information exchange adequacy and usefulness, patients’ satisfaction with care and the information they receive, and rates of rehospitalization, post-discharge emergency department visits, and PCP followup visits. The information technology cost of implementing and maintaining the Virtual Continuity intervention will also be assessed.

Specific Aims:
  • Augment the present system of PCP notification through the development and use of electronic EMR links to allow virtual continuity for the PCP. (Ongoing)
  • Measure differences in patient care safety and quality between PCPs receiving virtual continuity versus usual communication in a pre-post study. (Ongoing)
  • Evaluate the impact of virtual continuity. (Upcoming)

2010 Activities: A steering committee and a working group consisting of project investigators and UPMC Information Services Department personnel continued to meet regularly to develop procedures that will allow enhanced hospital to PCP communication to occur. Planning of specific processes to implement and maintain the virtual continuity communication intervention is ongoing.

Physicians who serve as PCPs and are employed by the University of Pittsburgh or by UPMC, in concert with the UPMC Office and Physician Relations, have been recruited to participate in the study. Two research assistants have been hired. Patient recruitment and pilot data collection began in September 2010.

Grantee's Most Recent Self-Reported Quarterly Status (as of December 2010): There has been slippage with project milestones because of delays initiating data collection with hospital patients. The data collection was expected to begin in October after the pilot was completed and is now expected to begin in February 2011. The budget is underspent as a result of project delays and difficulty hiring staff.

Impact and Findings: The Delphi PCP survey was conducted via a Web-based interface. Rated items in the first round having a 95 percent confidence interval lower boundary of 4.0 or more were defined as accepted by the panel. Items with a 95 percent confidence interval upper boundary less than 3.0 were rejected. All other items were defined as indeterminate. In the second round of the survey, the panel was asked to reconsider those indeterminate data items, showing them their prior rating and the group mean for each item in an effort reach further consensus on those items.

In the first round of the Delphi survey, 37 of 89 items were accepted, one was rejected, and 51 were indeterminate. The second round survey considered these 51 indeterminate items and consensus to accept was found on 6 more items.

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Knowledge Creation

Virtual Continuity and its Impact on Complex Hospitalized Patients' Care - Final Report

Citation:
Smith K. Virtual Continuity and its Impact on Complex Hospitalized Patients' Care - Final Report. (Prepared by the University of Pittsburgh under Grant No. R18 HS018151). Rockville, MD: Agency for Healthcare Research and Quality, 2013. (PDF, 159.53 KB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
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