Call me maybe? ED patients say, please do

Emergency patients who received follow-up phone calls or emails from their emergency physicians were more satisfied with their emergency department experience than those who were not contacted. The results of patient satisfaction surveys completed by more than 1,000 patients were reported online in the Annals of Emergency Medicine .  

"The benefits of higher patient satisfaction range from better patient compliance with discharge instructions to higher staff morale," said lead study author Pankaj Patel, M.D., of Kaiser Permanente Medical Center in Roseville, Calif. "Contacting patients after they leave the ER may also improve transitions of care, which is a growing focus for emergency physicians. A quick follow-up with our patients may help reduce return visits to the ER and readmission to the hospital."

For one month, 42 emergency physicians either emailed or telephoned their patients within 72 hours of being discharged from the ED. The subsequent month, physicians provided no follow-up contact. The average satisfaction score given by the 348 patients who received follow-up contact was 87.7 percent. The average satisfaction score for the 1,002 patients who received no follow-up contact was 79.4 percent.

Higher patient satisfaction was observed equally among all patients contacted by email and those contacted by telephone. Physicians preferred using post-ED visit email contact over telephone contact because email contact took less time (2.2 minutes for email vs. 3.6 minutes for telephone).

"Our top priority is to give excellent care to our patients, but if we can increase their satisfaction with that care, that may lead to better outcomes in the long term," said Patel. "A brief conversation outside the rushed and stressful environment of the ER between patient and physician can significantly improve the patient's impression of their experience. Higher patient satisfaction correlates to better patient compliance and lower risk of medical liability. Everybody wins."

'Paper chart' model of computerized provider documentation seen as problematic

As health care practitioners and institutions increase their adoption and use of electronic health records, the transition from paper-based to computerized provider documentation is having dramatic effects on a range of health care and business processes, and not all of them positive.

In a study led by Peter Embi, M.D., a physician-scientist and vice-chair of The Ohio State University College of Medicine's Department of Biomedical Informatics, researchers from Ohio State College of Medicine analyzed feedback from 129 participant stakeholders, including 54 physicians and practitioners, 34 nurses and 37 administrators at five Department of Veterans Affairs medical facilities across the country.

"By studying the views of different types of professionals at multiple national sites, we were able to expand on previous research related to this new way of documenting clinical care," says Embi.

Among the findings, published online ahead of print in the Journal of American Medical Informatics Association, the researchers identified a range of impacts from CPD affecting critical clinical and administrative workflows and communication patterns. "As CPD use increases and becomes the major way we capture clinical information in health care, it is affecting processes that impact clinical understanding, decision-making and communication," Embi adds.

The study's findings were grouped into five major themes of CPD impacts related to:

  • Communication and coordination
  • Control and limitations in expressivity
  • Information availability and reasoning support
  • Workflow alteration and disruption
  • Trust and confidence concerns

While current CPD systems were felt to be, overall, better than paper, and were beneficial, they often fell short of meeting users' needs or led to problems, in part, because of what study authors attribute to an outdated 'paper chart' paradigm.

Researchers noted the same user types also shared common views, but they noted some important differences regarding the perceived purpose and effects of CPD between clinicians and administrators. For example, in general, the administrative group valued the completeness facilitated by templates, while the practitioner and nurse groups noted that, while templates could help facilitate documentation, restrictive templates generated less informative documentation than free text.

"The need for easy and rapid, yet structured and constrained, documentation often conflicts with the need for highly reliable and retrievable information to support clinical reasoning and workflows," Embi and colleagues say. They also noted a tension between efficient documentation and the need for accurate data collection to enable quality improvement and research, often limited by overuse of CPD features such as copy-and-paste.

Along with Embi, researchers from the University of Utah, the University of Washington and Puget Sound Healthcare System in Seattle participated in this research, which was funded by the U.S. Department of Veterans Affairs.

Electronic health communications often unavailable to lower-income patients

Lower-income patients want to communicate electronically with their doctors, but the revolution in health care technology often is not accessible to them because of inadequate services within the health care clinics they frequent, according to a survey by UC San Francisco researchers.

Increasing numbers of health care systems are offering online services to patients in order to manage care outside of office visits, and this often includes the ability for patients to communicate electronically with health care providers.

The UCSF research team found that a significant majority of uninsured and underinsured patients currently use email, text messaging, and the Internet in their everyday lives and would like to extend that to their health care, but the "safety net" clinics they use generally do not offer the necessary patient portal or secure messaging to support this communication.

"Electronic health-related communication is becoming the standard of care in well-resourced settings, and should be implemented and supported in resource-poor settings," said senior author Urmimala Sarkar, MD, MPH, who is an assistant professor of medicine with the UCSF Department of Medicine, Division of General Internal Medicine, and the UCSF Center for Vulnerable Populations at San Francisco General Hospital and Trauma Center.

The analysis was reported online in the Journal of General Internal Medicine.

The study surveyed 416 patients seen in six San Francisco Department of Public Health community clinics serving primarily uninsured and publicly insured patients. Participants were ethnically and racially diverse, low-income, spoke twenty-four different primary languages and were generally representative of the overall clinic network population. Fifty-four percent said they obtained general information from the Internet.

While 17 percent of patients currently reported using email informally with health providers as a part of their care, the vast majority (78%) of respondents expressed interest in electronic communication. In addition, 60 percent of those surveyed were current email users, suggesting that the majority of vulnerable patients served in these clinics already had both some level of computer access and Internet skills.

Although a recent national study suggested that three-fourths of patients were interested in such electronic communication, there has been little research to understand interest among lower income patients, such as those receiving care at public clinics, as these patients are somewhat less likely to have access to computers and/or the Internet.

"Patients were largely in favor of using email technology for health and agreed it would likely improve overall clinical communication and efficiency," said lead author Adam Schickedanz, MD, a medical resident in the UCSF Department of Pediatrics. "Our work makes it clear that lower income patients from a wide variety of backgrounds want to be part of the health information technology revolution.

"The question is whether they will be afforded the opportunities to take part in the same way as their middle and higher-income peers," he said.

According to researchers, future research should aim to understand diverse patient preferences for ultimately engaging in electronic communication with providers, including additional tailoring of existing systems to support language- and literacy-appropriate access.
Other study authors are David Huang, M.D., of the UCSF Department of Internal Medicine; Andrea Lopez and C.R. Lyles of the Center for Vulnerable Populations at San Francisco General Hospital and the UCSF Department of Internal Medicine; Tom Bodenheimer, M.D., of the UCSF Department of Family and Community Medicine; and Edna Cheung of UC Berkeley.


Hospitals should reconsider insulin pen use, says ISMP

As a result of persistent, ongoing safety issues, the Institute for Safe Medication Practices is calling for hospitals to closely re-examine their policies regarding insulin pen devices, and consider transitioning away from insulin pens for routine inpatient use.

Studies have shown a risk of infection when insulin pens are reused for more than one patient, since blood and tissue can travel back into the cartridges after injection. It was announced early this year that almost 2,000 patients in a New York hospital may have been inadvertently exposed to HIV, hepatitis B, or hepatitis C because of the reuse of insulin pens on multiple patients, even after changing the disposable needle.

Another New York hospital also announced possible exposure of more than 700 patients to bloodborne pathogens due to improper sharing of pens among inpatients, and similar cases in Texas and Wisconsin have been covered in the ISMP Medication Safety Alert! newsletter. ISMP has received multiple additional reports involving smaller numbers of patients.

Insulin pens offer convenience and may help prevent certain types of medication errors; however, they were originally developed for use in ambulatory care, not hospitals. Placing a label on an insulin pen for a single patient is difficult. In addition, the use of insulin pen cartridges as multiple dose vials, the risk of needlestick injuries, and user technique errors have all been identified as serious concerns with pen use in hospital settings.

The U.S. Food and Drug Administration and Centers for Disease Control and Prevention caution insulin pen users to remove the needle immediately after injection and warn against sharing the device between patients. However, despite educational efforts and monitoring, reports of patients placed at risk of infection continue to surface.