Patient-Centered Toolkit Provides Shared Discussion Space

Nancy A. Melville

March 31, 2014

LAS VEGAS — An innovative Web-based, patient-centered toolkit is being developed at Brigham and Women's Hospital in Boston, with the intention of breaking down communication barriers between patients and providers in an acute-care setting.

A key feature of the toolkit is a microblog where patients will be able to post questions or concerns about their care using an interface accessible by all providers involved in their case. Providers will use the microblog to respond and make sure the questions are addressed in a timely manner.

"The idea behind this is to have all of the conversation in one universal space," said Anuj K. Dalal, MD, an internist at Brigham and Women's Hospital.

"This represents a huge change from what we are traditionally used to doing in the clinical setting — instead of having one intern or single provider being responsible for all of the communication to a patient, this makes sure everyone is aware of all of the information at once."

Dr. Dalal described the patient-centered toolkit here at Hospital Medicine 2014.

The toolkit is being designed as a component of the Promoting Respect and Ongoing Safety through Patient-centeredness, Engagement, Communication, and Technology (PROSPECT) initiative at the hospital, and is funded by a $2 million grant from the Gordon and Betty Moore Foundation.

In addition to the microblog, the toolkit allows patients in the acute-care postdischarge setting to look up reliable educational information on their health conditions, view information on their medications, and evaluate test results.

Dr. Dalal said the program differs from existing applications in various ways. Importantly, the tool will serve as a portal for all of the patient's care providers, not just those at the hospital, he said.

"We know care team utilization and multidisciplinary rounds definitely improve communications, safety, and efficiency, but what about the primary care physicians and consultants who are offsite? And what about patient caregivers? This brings them into the dialogue as well."

In addition, existing patient portal programs can be valuable in the ambulatory setting but haven't been properly evaluated or validated in the inpatient or transition setting, he said.

"The programs that are available don't reliably identify caregivers or deliver tailored education. Nor do they solicit real-time input that's fed back to patients or providers or facilitate this kind of seamless dialogue," he said.

Not all discussion in the patient-centered toolkit has to be shared in the open; the program is designed to provide separate patient and provider messaging threads to allow for the option of discussion in a private virtual space, if desired.

All users, however, are able to view the patient's plan of care, which Dr. Dalal underscored is particularly important in light of common inconsistencies between patients and providers on perceived healthcare goals, as seen in a survey the team conducted.

"We asked ICU and oncology patients, their physicians, and bedside nurses one simple question: What is the primary goal for the patient's care — to be curative, to live longer, or improve health?" he said.

It turned out that the patient, the physician, and the bedside nurse agreed on the same response in only 21 of 88 (24%) of cases.

"It's clear that if we are going to engage patients during hospitalization, an intermediary goal must be to get patients and providers on the same page," said Dr. Dalal.

Another important aspect of the toolkit that sets it apart from traditional medical records is that information is posted, and accessed, in real time, he added.

"I think of one of the biggest failings of electronic medical records is that they are sort of static," he said.

"We know the plan of care is dynamic, it is continuously evolving, and the idea of using a Web-based tool like this is that you can really manage things in real time."

No Central Point of Contact?

Comoderator and visiting professor Talmadge E. King Jr, MD, chair of the Department of Medicine at the University of California, San Francisco, expressed concern that the toolkit could affect the traditional role of having a single point of contact for the patient.

"What I wonder about is whether this allows 1 person to be responsible for communicating with the patient. How do you tie these 2 things together?" he asked.

Asked to comment on the toolkit for Medscape Medical News, Jeffrey W. Petry, MD, regional medical director for Cogent Healthcare's Hospitalist Management Group in Dayton, Ohio, said, "It sounds brilliant, but I'm skeptical."

He seconded Dr. King's concern about the program appearing to potentially negate the role of a central point of contact for the patient.

"Depending on the culture of the hospital you practice in, the hospitalist, as the attending physician, is in command of the care, captain of the ship, and owns all the quality data and outcomes. With this kind of system, he may not be given the measure of respect that he should have."

Without that central figure, communication could in fact become worse, rather than better, he suggested.

"Another problematic issue is having private threads; it seems contradictory to the whole purpose of the program," he added.

More traditional protocols, if followed appropriately, should facilitate patient and provider communication, said Dr. Petry.

"This microblog certainly could be a communication tool, but it's hard for me to believe it could be superior to adequate documentation in a medical record and team-based rounding where I'm at the bedside with the oncologist and the nurse and the entire team."

Dr. Dalal and his colleagues are enrolling 4500 patients who are being admitted to randomized intensive care, oncology, and medicine units to evaluate the toolkit. Dr. Dalal and Dr. Petry have disclosed no relevant financial relationships.

Hospital Medicine 2014. Presented March 26, 2014.

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