Peggy Preusse

Adverse Drug Events After Hospital Discharge in Older Adults: Types, Severity, and Involvement of Beers Criteria Medications

To characterize adverse drug events (ADEs) occurring within the high‐risk 45‐day period after hospitalization in older adults.

An electronic health record-based intervention to increase follow-up office visits and decrease rehospitalization in older adults

To assess the effect of an electronic health record–based transitional care intervention involving automated alerts to primary care providers and staff when older adults were discharged from the hospital.

Improving Rates of Influenza Vaccination Through Electronic Health Record Portal Messages, Interactive Voice Recognition Calls and Patient-Enabled Electronic Health Record Updates: Protocol for a Randomized Controlled Trial

Background Clinical decision support (CDS), including computerized reminders for providers and patients, can improve health outcomes. CDS promoting influenza vaccination, delivered directly to patients via an electronic health record (EHR) patient portal and interactive voice recognition (IVR) calls, offers an innovative approach to improving patient care. Objective To test the effectiveness of an EHR patient portal and IVR outreach to improve rates of influenza vaccination in a large multispecialty group practice in central Massachusetts. Methods We describe a nonblinded, randomized controlled trial of EHR patient portal messages and IVR calls designed to promote influenza vaccination. In our preparatory phase, we conducted qualitative interviews with patients, providers, and staff to inform development of EHR portal messages with embedded questionnaires and IVR call scripts. We also provided practice-wide education on influenza vaccines to all physicians and staff members, including information on existing vaccine-specific EHR CDS. Outreach will target adult patients who remain unvaccinated for more than 2 months after the start of the influenza season. Using computer-generated randomization and a factorial design, we will assign 20,000 patients who are active users of electronic patient portals to one of the 4 study arms: (1) receipt of a portal message promoting influenza vaccines and offering online appointment scheduling; (2) receipt of an IVR call with similar content but without appointment facilitation; (3) both (1) and (2); or (4) neither (1) nor (2) (usual care). We will randomize patients without electronic portals (10,000 patients) to (1) receipt of IVR call or (2) usual care. Both portal messages and IVR calls promote influenza vaccine completion. Our primary outcome is percentage of eligible patients with influenza vaccines administered at our group practice during the 2014-15 influenza season. Both outreach methods also solicit patient self-report on influenza vaccinations completed outside the clinic or on barriers to influenza vaccination. Self-reported data from both outreach modes will be uploaded into the EHR to increase accuracy of existing provider-directed EHR CDS (vaccine alerts). Results With our proposed sample size and using a factorial design, power calculations using baseline vaccination rate estimates indicated that 4286 participants per arm would give 80% power to detect a 3% improvement in influenza vaccination rates between groups (α=.05; 2-sided). Intention-to-treat unadjusted chi-square analyses will be performed to assess the impact of portal messages, either alone or in combination with the IVR call, on influenza vaccination rates. The project was funded in January 2014. Patient enrollment for the project described here completed in December 2014. Data analysis is currently under way and first results are expected to be submitted for publication in 2016. Conclusions If successful, this study’s intervention may be adapted by other large health care organizations to increase vaccination rates among their eligible patients. ClinicalTrial ClinicalTrials.gov NCT02266277; https://clinicaltrials.gov/ct2/show/NCT02266277 (Archived by WebCite at http://www.webcitation.org/6fbLviHLH).

Consumer Health Informatics Interventions Must Support User Workflows, Be Easy-To-Use, and Improve Cognition: Applying the SEIPS 2.0 Model to Evaluate Patients’ and Clinicians’ Experiences with the CONDUIT-HID Intervention

ABSTRACT The aim of this research was to gain a holistic understanding of patients’ and clinicians’ experiences with the CONDUIT-HID (CONtrolling Disease Using Inexpensive Technology—Hypertension In Diabetes) intervention, intended to be a technology-enabled consumer health informatics (CHI) approach to control hypertension. We examined patients’ experiences utilizing the technologies to share patient blood pressure data with their care team via a qualitative analysis of patient (n = 21) and clinician (n = 5) interviews. Using the SEIPS 2.0 sociotechnical systems model, our evaluation revealed that minimizing usability issues and supporting participant workflow were important—but not sufficient—for CHI intervention success. The ability of the CHI intervention to support the cognitive development of patients’ self-management skills and to facilitate strategic collaboration among care team members was also important. These insights can provide CHI and the human–computer interaction (HCI) communities with a framework of generalizable findings to better design future CHI interventions.

Improving Rates of Outpatient Influenza Vaccination Through EHR Portal Messages and Interactive Automated Calls: A Randomized Controlled Trial

BackgroundPatient reminders for influenza vaccination, delivered via electronic health record (EHR) patient portal messages and interactive voice response (IVR) calls, offer an innovative approach to improving patient care.ObjectiveTo test the effectiveness of portal and IVR outreach in improving rates of influenza vaccination.DesignRandomized controlled trial of EHR portal messages and IVR calls promoting influenza vaccination.ParticipantsAdults with no documented influenza vaccination 2 months after the start of influenza season (2014–2015).InterventionUsing a factorial design, we assigned 20,000 patients who were active portal users to one of four study arms: (a) receipt of a portal message promoting influenza vaccines, (b) receipt of IVR call with similar content, (c) both a and b, or (d) neither (usual care). We randomized 10,000 non-portal users to receipt of IVR call or usual care. In all intervention arms, information on pneumococcal vaccination was included if the targeted patient was overdue for pneumococcal vaccine.Main MeasuresEHR-documented influenza vaccination during the 2014–2015 influenza season, measured April 2015.Key ResultsAmong portal users, 14.0% (702) of those receiving both portal messages and calls, 13.4% (669) of message recipients, 12.8% (642) of call recipients, and 11.6% (582) of those with usual care received vaccines. On multivariable analysis of portal users, those receiving portal messages alone (OR 1.20, 95% CI 1.06–1.35) or IVR calls alone (OR 1.15 95% CI 1.02–1.30) were more likely than usual care recipients to be vaccinated. Those receiving both messages and calls were also more likely than the usual care group to be vaccinated (ad hoc analysis, using a Bonferroni correction: OR 1.29, 97.5% CI 1.13, 1.48). Among non-portal users, 8.5% of call recipients and 8.6% of usual care recipients received influenza vaccines (p = NS). Pneumococcal vaccination rates showed no significant improvement.ConclusionsOur outreach achieved a small but significant improvement in influenza vaccination rates.Registration: ClinicalTrials.gov Identifier NCT02266277 (https://clinicaltrials.gov/ct2/show/NCT02266277).

B3-4: Identification of Adverse Drug Events Post-Hospital Discharge in a Geriatric Population.

Background/Aims Adverse drug events (ADEs), especially those that may be preventable, are among the most serious concerns regarding medication use in older persons. The purpose of this study was to describe the incidence, severity and preventability of ADEs occurring within 45 days post-hospitalization in an ambulatory geriatric population. Methods We studied 1000 consecutive discharges of patients aged 65 and older who received medical care from a large multispecialty medical group in Central Massachusetts. Discharges were excluded if the discharge diagnosis was psychiatric or if discharges were not to home. Three clinical pharmacist investigators reviewed the ambulatory records of each discharged patient to identify drug-related incidents occurring during the 45-day period post hospital discharge. Drug-related incidents were presented to a pair of physician-reviewers who independently classified incidents as to whether an adverse drug event was present, the severity of the event, and whether the event was preventable. When the physician-reviewers disagreed on the classification of an incident, they met and reached consensus; consensus was reached in all instances where there was initial disagreement. Results There were 242 ADEs identified, of which 35% (n = 84) were considered preventable. Of the preventable ADEs, 63% (n = 53) were categorized as significant, 32% (n = 27) were serious, and 5% (n = 4) were life-threatening. Nearly half of all ADEs occurred within the first two weeks following discharge. Conclusions Adverse drug events are common and often preventable among older persons in the ambulatory setting. The substantial portion of serious events that were considered preventable suggests opportunities for improving care during the post-hospital discharge period.

CC1-02: Technological Resources and Personnel Costs Required to Implement an Automated Alert System for Primary Care Physicians When Patients Transition from Hospitals to Home

Background/Aims With the adoption of electronic medical records (EMR) by medical group practices, there are opportunities to improve the quality of care for patients who are discharged from hospitals and intermediate care facilities. While transitions within vertically-integrated healthcare systems are amenable to EMR-based transition interventions, there is little guidance for medical groups without integrated hospital-EMR access who wish to automate the flow of patient information during critical transitions in care. Our aim was to describe the technological resources, expertise and time needed to develop and implement an automated system providing critical information and alerts to primary care physicians when their patients transition from hospitals or skilled nursing facilities to home. Methods Within a large medical group practice with an EMR, we developed and implemented an automated alert system that provides notification of discharges, reminders of the need for follow-up visits, new drugs added during the in-patient stay, warnings about drug-drug interactions, and recommendations for dosing changes and laboratory monitoring of high risk drugs. We tracked components of the information system required to accomplish this as well as the time spent by team members. We used US national averages of relevant hourly wages to estimate personnel costs. Results Critical components of the information system are notifications of hospital discharges through an admission, discharge and transfer registration (ADT) interface, linkage to the group practice scheduling system, timely access to information on pharmacy dispensing and lab tests, and an interface engine to direct messages to specific physicians and staff. Total personnel cost was

PS2-13: Why Patients Fail to Complete Laboratory Monitoring Requests

76,314. Nearly half (47%) was for 614 hours by physicians who developed content, provided overall project management, and reviewed alerts during a test period to ensure that only “actionable” alerts would be sent. Discussion Implementing a system to provide a flow of critical information about patient transitions requires strong internal informatics expertise, cooperation between facilities and ambulatory providers, development of a number of electronic linkages, and extensive commitment of physician time.

Technological resources and personnel costs required to implement an automated alert system for ambulatory physicians when patients are discharged from hospitals to home

Background/Aims Inadequate laboratory monitoring of high-risk medications is a medical error associated with preventable adverse drug events. Patient failure to complete ordered laboratory tests is not uncommon. We conducted in-depth interviews with patients who did not complete a recently ordered laboratory test to identify barriers to test completion. Methods The target population was patients in a large multispecialty group practice who failed to complete an ordered laboratory test. We conducted semi-structured interviews with 18 patients who did not complete a monitoring test order related to 1 of 7 high-risk medications (angiotensin converting enzyme inhibitors (ACE) inhibitors, angiotensin II receptor blockers (ARBs), digoxin, phenytoin, statins, thyroid replacement hormone, or valproic acid) between July 2008 and October 2010. For comparison, we also interviewed 5 patients who completed all ordered laboratory tests. The interviews occurred in person when possible (n=17) as well as by phone (n=6). All interviews were recorded and transcribed and analyzed using a grounded theory approach. Results The laboratory monitoring discussions included the following themes: physician communication about lab tests, patient comprehension of lab test purpose, patient attitude toward lab tests, and barriers to test completion. The most prominent barrier to test completion was forgetting. Patients often did not realize they had missed an ordered test. When patients did acknowledge missing an ordered test, they often noted that they did not encounter any barriers besides forgetting. Regarding potential interventions, patients reported that understanding the indication for the tests would not help reduce non-completion. Several patients understood the reason for the test, but still failed to complete it. While some thought it was important to understand the reason for the test, others trusted their physician and did not believe it was essential to understand. Some patients were using an online personal health portal system offered through the practice that included information about upcoming tests. Conclusions Forgetting was the most prominent theme for non-completion of ordered test. Patients felt that providing timely (near desired test completion date) patient reminders, either by phone or by e-mail, would likely improve completion rates of laboratory monitoring for high-risk medications, while providing more information about the test indication would not.