Keywords
smartphone - text message - patient education - discharge instruction - emergency
medicine
Background and Significance
Background and Significance
Successful care transition after emergency department (ED) encounters requires patient
comprehension and adherence to post-discharge instructions. ED visits frequently last
several hours, involving numerous tests and treatments resulting in new diagnoses
and medications, changes to medication regimens and post-discharge appointments.[1] From a patient perspective, this can be the end of an exhausting health care encounter,
a time when information comprehension and retention are suboptimal.[2]
[3]
[4] Research shows that both poor comprehension and low adherence to post-ED care instructions
contribute to high ED return rates and adverse events.[5]
[6]
[7] Verbal ED discharge instructions alone are insufficient and lead to deficient patient
comprehension on diagnosis, care plans, and return needs.[4]
[8]
[9] Many institutions provide written discharge instructions from the ED, but these
paper documents are prone to be displaced by patients and caregivers, and in worst-case
scenarios may result in patient safety events errors.[10]
Emergency medicine has increasingly embraced the concept of care coordination to improve
the quality of transition of care, but randomized studies have showed variable impact
in improving follow-up rates and repeat ED visits.[11]
[12] Other work has demonstrated that the use of web-based, standardized communication
systems between ED and primary care physicians improves continuity of care, increasing
the usefulness of transferred information and improving outpatient providers perceived
patient knowledge and patient management.[13]
[14] The Health Information Technology for Economic and Clinical Health (HITECH) Act,
established in 2009, encourages the meaningful use of electronic health records (EHRs)
to further the quality of care received by patients.[15] Recent advances in communication technologies, as well as growing public interest,
have facilitated the growth of personal health records (PHRs), with the AHA now reporting
that 93% of the hospitals now allow patients online access to EHRs via patient portals.[16]
[17] PHR are web-based platforms “tethered” to an EHR, designed to give patients improved
access to their health care information.[18]
[19] Many current PHRs have interactive functionality such as ordering prescriptions,
scheduling appointments, secure messaging with providers, and remote patient monitoring,
and have demonstrated improvements in medication adherence, disease management, patient–provider
communication, and satisfaction with care.[20]
[21]
[22]
[23]
[24]
[25] However, there is variable patient engagement with PHRs, including large racial/ethnic
disparities.[26] Furthermore, not every patient visiting the ED is part of the associated health
care system, reducing the incentive for portal use. Despite the critical importance
of care transitions and the progress in PHRs, technological innovation focused on
the ED discharge process has been limited.[27] Recent literature suggests that digital communication incorporated into post-ED
care can improve patient satisfaction and care quality.[28]
[29]
In 2019, a smartphone-based, electronic ED discharge process, MyEDCare, was piloted
at an urban academic medical center. The medical center is composed of two geographically
distinct urban hospital-based EDs: a large quaternary care academic hospital and a
medium-sized community hospital, neither with an available PHR tethered to the ED
EHR at the time of study. Together these sites provide care for nearly 140,000 encounters
annually and, at the time of this study, utilized Allscripts EHR (Allscripts Healthcare
Solutions, Inc.).
MyEDCare is an innovative and patient-centered discharge workflow, leveraging modern-day
reliance on smartphones as a universal communication device. The primary goals of
MyEDCare were to modernize patient access to high-quality discharge instructions and
optimize information comprehension in the process, reducing the risk of adverse events
associated with noncompliance, and lessening the likelihood of avoidable health care
utilization.[30]
[31] Furthermore, MyEDCare was designed to reduce duplicative testing by allowing future
caregivers to immediately access the test results performed during the index ED encounters.
Objectives
This study evaluated the feasibility of utilizing MyEDCare as a discharge process.
We measured the provider and patient acceptance, changes in the number of ED return
visits, and patient satisfaction of receiving electronic discharge information and
diagnostic test results to their smartphones as a comprehensive post-ED communication
device.
Methods
Standard ED discharge process involves providers entering discharge instructions into
the EHR, which are then printed out as multiple paper documents at the time of patient
discharge. ED nursing then reviews the content of these documents with the patient
to complete the discharge process. MyEDCare was designed as a paperless discharge
process for adult patients (21 years old and above), enabling patient-specific ED
discharge instructions and ED test results to be viewed and saved on the patient's
smartphone device. MyEDCare is proprietary, developed at the study site by many of
the authors in the paper in collaboration with the Institution's Informatics Department.
Patients discharged from the ED who did not opt-out from MyEDCare were enrolled in
the process. For patient safety, the following cohorts were also excluded from MyEDCare
discharge process and received standard paper-format discharge instructions: patients
discharged to locations that would require paper documentation (e.g., to law enforcement
custody, skilled care facilities, shelters), patients whose employers requested discharge
paperwork, patients discharged with a primary psychiatric diagnosis, and patients
who were determined by providers to not have sufficient English proficiency. As MyEDCare
is an ED discharge process, patients admitted to the hospital and discharged from
inpatient services were also excluded.
To enroll a patient in MyEDCare, the ED physician confirms eligibility of the patient
via verbal consent and verification so that he or she is in possession of a functional
smartphone with cellular service while in the ED. Patients could designate a proxy
smartphone to a family member, provided if the phone was present with the patient
at the time of ED discharge, to complete MyEDCare discharge process. The physician
enters the confirmed phone number into the EHR in a designated section modified specifically
for MyEDCare. The physician then places the “ED Discharge Order” in the EHR; this
order finalizes MyEDCare enrollment process, triggering the cellular service contracted
at our institution to generate a text message encoded with a patient-specific hyperlink
that gives access to the discharge documents. The text message is then sent to the
patient's smartphone via the cellular carrier affiliated with the phone number. Patients
typically receive the text message within 20 seconds of the EHR discharge order being
placed.
The text message includes a password-protected hyperlink to a Health Insurance Portability
and Accountability Act (HIPAA)-secure website, with brief instructions on how to access
the content. The HIPAA-secure platform contains a nonstandardized patient-specific
information, entered by the ED providers as part of the pre-existing EHR documentation
workflow prior to patient discharge and extracted automatically from the EHR into
the MyEDCare online platform. Each patient's MyEDCare platform includes the following
information under discrete sections: (1) results of any laboratory and radiological
diagnostic testing performed in the ED, (2) information on any new medications prescribed
by the ED care team, (3) instructions on when to return to ED, including ExitCare
(diagnosis-specific peer-reviewed patient education and discharge instructions by
Elsevier), (4) any scheduled outpatient care appointments and relevant contact information.
The online layout was designed to improve patient navigation of their comprehensive
post-ED care plan, compared with the multiple paper documents generated in a standard
paper-format discharge, including a reduced number of “pages” on the platform. The
generic MyEDCare platform display was in English only, but patient-specific discharge
instruction content entered by the ED provider and automatically extracted from the
EHR was not limited to a single language. [Fig. 1] shows the interface of MyEDCare.
Fig. 1 MyEDCare smartphone interface.
Upon receiving the text message, the ED nurse guides the patient in their first access
of MyEDCare online content, using their date of birth as the patient-specific password
for HIPPA compliance. The ED nurse member then reviews the electronic discharge documents
on the phone in real-time, confirming content accuracy and patient comprehension,
using teach-back method to optimize retention.[32] Patients formally confirm receipt and comprehension of the discharge instructions
using electronic signature pads connected to the EHR. This completion of the paperless
MyEDCare ED discharge process takes approximately the same time a nurse would spend
reviewing standard paper discharge instructions: 2 to 5 minutes per patient, depending
on case details. Some patients were enrolled in MyEDCare but either did not receive
the text message while in ED or could not access the online platform from the text
hyperlink. These patients experiencing an incomplete MyEDCare discharge process subsequently
received standard paper-format discharge instructions. Scenarios leading to an incomplete
MyEDCare discharge process included: lack of smartphone PDF viewing software required
to view content, smartphone malfunction or loss of power, data plans prohibiting access
to MyEDCare online content, limitations to cellular carrier service, or nonfunctional
hyperlinks.
The documents are capable of being downloaded to the patient's smartphones in a PDF
format to facilitate the electronic transfer to family and health care providers at
the patient's discretion. With the goal of optimizing engagement in post-ED care,
similar text messages encoded with the same hyperlink and protected information are
automatically generated and sent to patients 48 hours after ED discharge and again
at 29 days. Patients can continue to access their online content for 30 days after
ED discharge. Patients receiving electronic discharge could also receive paper documents
if specifically requested.
This process was piloted for 9 months starting on March 20th, 2019 at the two EDs, respectively. Data collection for evaluation was performed
throughout the pilot on a weekly basis. Upon completion of the program, we measured
the percentage of ED patients who were enrolled in MyEDCare, including their demographics,
subsequent completion or incompletion of MyEDCare discharge process, and the number
of times patients accessed the platform post-discharge. We neither measured the access
times or dates to relate them to the three text messages sent over 30 days, nor determined
how frequently patients downloaded the content in the PDF format. The MyEDCare discharge
performance, including both complete and incomplete MyEDCare, was compared against
the standard paper discharge process for patients who presented to the ED during the
9-month pilot. We also measured return visits to the ED within 72 hours, 9 days, and
30 days of discharge, subdivided into scheduled and unscheduled (e.g., suture removals,
wound checks) return visits. For statistical analysis, Chi-square or Fisher's exact
test was used to compare categorical variables, and Wilcoxon rank sum test was used
for continuous variables after checking normality. Q–Q plot was used to check the
normality for continuous variables. Moreover, a logistic regression was used to analyze
MyEDCare access as the dependent variable. Variables listed in [Table 1] were used as the independent variables.
Table 1
Characteristics of patients enrolled in MyEDCare
|
N (%)/Mean (SD)
|
Enrolled in MyEDCare (N = 27,713)
|
Completed MyEDCare discharge (N = 16,933)
|
Incomplete MyEDCare discharge[b] (N = 10,780)
|
Paper-discharge[c] (N = 36,180)
|
|
ED site
|
|
|
|
|
|
Cornell ED
|
16,992 (61.3%)
|
10,447 (61.7%)
|
6,545 (60.7%)
|
20,370 (56.3%)
|
|
LMH ED
|
10,721 (38.7%)
|
6,486 (38.3%)
|
4,235 (39.3%)
|
15,810 (43.7%)
|
|
Marital status[a]
|
|
|
|
|
|
Married
|
8,660 (31.2%)
|
5,501 (32.5%)
|
3,159 (29.3%)
|
9,859 (27.7%)
|
|
Nonmarried
|
19,053 (68.8%)
|
11,432 (67.5%)
|
7,621 (70.7%)
|
25,749 (72.3%)
|
|
Female
|
16068 (58.0%)
|
9,873 (58.3%)
|
6,195 (57.5%)
|
18,465 (51.4%)
|
|
English as primary langauge[a]
|
24,249 (87.5%)
|
14,969 (88.4%)
|
9,280 (86.1%)
|
30,582 (85.2%)
|
|
Race[a]
|
|
|
|
|
|
Asian
|
1,815 (6.5%)
|
1,172 (6.9%)
|
643 (6.0%)
|
3,215 (9.5%)
|
|
Black or African American
|
6,162 (22.2%)
|
3,291 (19.4%)
|
2,871 (26.6%)
|
8,118 (24.1%)
|
|
Other
|
8,689 (31.4%)
|
5,344 (31.6%)
|
3,345 (31.0%)
|
7,835 (23.3%)
|
|
White
|
11,047 (39.9%)
|
7,126 (42.1%)
|
3,921 (36.4%)
|
14,501 (43.1%)
|
|
Payor[a]
|
|
|
|
|
|
Commercial
|
15,129 (54.6%)
|
10,363 (61.2%)
|
4,766 (44.2%)
|
12,299 (34.1%)
|
|
Medicaid
|
6,825 (24.6%)
|
3,644 (21.5%)
|
3,181 (29.5%)
|
10,430 (28.9%)
|
|
Medicare
|
3,889 (14.0%)
|
1,861 (11.0%)
|
2,028 (18.8%)
|
9,776 (27.1%)
|
|
Self-pay (NA)
|
1,870 (6.7%)
|
1,065 (6.3%)
|
805 (7.5%)
|
3,565 (9.9%)
|
|
ESI[a]
|
3.29 (0.61)
|
3.30 (0.61)
|
3.27 (0.61)
|
3.24 (0.64)
|
|
Age[a]
|
43.8 (16.4)
|
42.1 (15.7)
|
46.3 (17.2)
|
50.5 (19.61)
|
Abbreviations: ED, emergency department; ESI, emergency severity index; LMH, Lower
Manhattan Hospital.
a
p <0.05, comparing patients who completed MyEDCare and those who did not.
b Incomplete MyEDCare discharge (defaulted to standard paper-discharge process).
c Paper discharge process (excluded from MyEDCare prior to enrollment).
We solicited feedback via unstructured interviews from a convenience sample of ED
staff, including five providers, five nurses, and five patient navigators.[33] In the interviews, we asked for their feedback on (1) the usability of MyEDCare;
(2) patient safety of MyEDCare; (3) their subjective opinion of patient's responses
to MyEDCare; (4) the impact of MyEDCare on transition of care processes. We conducted
data collection and analysis in an iterative fashion. Additionally, we measured patient
comprehension of the ED encounter and discharge-related information using our performance
on six individual ED Consumer Assessment of Healthcare Providers and Systems (ED-CAHPS)
metrics.[34] Linear mean scoring was used in the calculation without case-mix adjustment.
Results
During the 9-month pilot, 27,713 patients were enrolled in the personal smartphone-based
MyEDCare discharge process, accounting for 43% of all treat-and-release patients discharged
from the ED. A total of 27% of treat-and-release patients completed MyEDCare ED discharge
process, accessing the online content (61% of all enrolled patients). [Fig. 2] displays the inclusion and exclusion criteria. On average, MyEDCare platform was
accessed twice per patient (SD = 1.63). [Table 1] shows the patient demographics and clinical profile of patients enrolled in MyEDCare;
discharged via MyEDCare; did not complete the MyEDCare process (so were converted
to discharge via standard paper discharge instructions) and were excluded for MyEDCare
prior to enrollment so received a planned discharge with standard paper discharge
instructions. As reported in [Table 1], no clinically meaningful differences in ESI levels or diagnosis types were observed
between patients who completed MyEDCare ED discharge process compared with those discharged
with standard paper discharge instructions. Conversely, we observed significant differences
in marital statuses, age, preferred language, insurance status and race as shown in
[Tables 1] and [2] (results from the regression model). Diagnoses that were most common among patients
who completed MyEDCare ED discharge process were chest pain, abdominal pain, headache,
cough, back pain, dizziness, fall, palpitations, syncope, and knee pain. Similarly,
diagnoses that were most common among patients discharged with standard paper discharge
instructions were chest pain, abdominal pain, headache, cough, fall, dizziness, back
pain, shortness of breath, unspecified abdominal pain, and syncope.
Fig. 2 Inclusion and exclusion criteria of MyEDCare.
Table 2
Regression results in assessing the factors associated with MyEDCare access
|
Variable
|
OR
|
p-Value
|
|
Gender (reference: female)
|
|
|
|
Male
|
0.925
|
0.002[b]
|
|
Race (reference: white)
|
|
|
|
Black or African American
|
0.668
|
< 0.001[c]
|
|
Asian
|
1.057
|
0.32
|
|
Other
|
0.910
|
0.003[b]
|
|
Language
|
|
|
|
Non-English
|
0.885
|
0.002[b]
|
|
Marital status
|
|
|
|
Nonmarried
|
0.870
|
0.002[b]
|
|
ED site
|
|
|
|
LMH
|
0.937
|
0.015[a]
|
|
Payor (reference: commercial)
|
|
|
|
Medicaid
|
0.561
|
< 0.001[c]
|
|
Medicare
|
0.625
|
< 0.001[c]
|
|
Self-pay
|
0.622
|
< 0.001[c]
|
|
Age
|
0.986
|
< 0.001[c]
|
|
ESI
|
1.084
|
< 0.001[c]
|
Abbreviations: ED, emergency department; ESI, emergency severity index; LMH, Lower
Manhattan Hospital; OR, odds ratio.
a
p < 0.05.
b
p < 0.01.
c
p < 0.001.
[Table 3] compares the ED return visit rate in patients who completed MyEDCare ED discharge
process versus those who were enrolled in MyEDCare but were ultimately discharged
via standard paper-based discharge instructions due to an incomplete MyEDCare ED discharge
process. Patients discharged via MyEDCare had less frequent unscheduled ED returns
at 72 hours (3.1 vs. 3.8%) and 30 days (9.4 vs. 12.8%) compared with patients with
incomplete (failed) MyEDCare enrollment (p-value = 0.003 and p-value < 0.001). For completion, [Table 4] shows the ED return visit rate comparing all patients enrolled in MyEDCare to those
discharged with standard paper-based discharge instructions. Patients enrolled in
MyEDCare also had less frequent unscheduled ED returns in 72 hours (3.4 vs. 5.6%)
and 30 days (10.7 vs. 16.9%) compared with patients discharged via conventional paper
workflows (p-value <0.001). Of the patient who completed MyEDCare discharge process, 9,051 (32.7%)
patients accessed just once. There are 1,009 patients who accessed the online content
at least five times. The average number of access does not include patients with incomplete
(failed) MyEDCare enrollment.
Table 3
Comparing ED utilization between patients who completed and did not complete MyEDCare
ED discharge process
|
Completed MyEDCare discharge (N,%)
|
Incomplete MyEDCare discharge (defaulted to paper-discharge) (N,%)
|
p-Value
|
|
Scheduled 72-h return
|
39 (0.2)
|
26 (0.2)
|
0.956
|
|
Unscheduled 72-h return[a]
|
526 (3.1)
|
406 (3.8)
|
0.003[b]
|
|
Scheduled 9-d return
|
103 (0.6)
|
60 (0.6)
|
0.640
|
|
Unscheduled 9-d return[a]
|
1,005 (5.9)
|
821 (7.6)
|
<0.001[c]
|
|
Scheduled 30-d return
|
152 (0.9)
|
86 (0.8)
|
0.417
|
|
Unscheduled 30-d return[a]
|
1,586 (9.4)
|
1,383 (12.8)
|
<0.001[c]
|
a
p-Value <0.05.
b
p-Value <0.01.
c
p-Value <0.001.
Table 4
Comparing ED Utilization between MyEDCare Enrollment and Paper Discharge
|
Enrolled MyEDCare (N, %)
|
Paper-discharge (N, %)
|
p-Value
|
|
Scheduled 72-h return
|
65 (0.2)
|
83 (0.2)
|
0.959
|
|
Unscheduled 72-h return[a]
|
932 (3.%)
|
2,035 (5.6)
|
<0.001[c]
|
|
Scheduled 9-d return
|
163 (0.%)
|
202 (0.6)
|
0.658
|
|
Unscheduled 9-d return[a]
|
1,826 (6.%)
|
3,743 (10.3)
|
<0.001[c]
|
|
Scheduled 30-d return
|
238 (0.9)
|
279 (0.8)
|
0.238
|
|
Unscheduled 30-d return[a]
|
2,969 (10.7)
|
6,106 (16.9)
|
<0.001[c]
|
a
p-Value <0.05.
b
p-Value <0.01.
c
p-Value <0.001.
[Table 2] shows the results from the regression model. Age had a significant impact on the
odds of completing the MyEDCare discharge process. One year increase in age was associated
with the odds decrease by 0.986 times (p < 0.001). Race played a role for Black or African American and Other but not for
Asian patients compared with White patients. Black or African American patients (OR = 0.668,
p < 0.001) and Other race patients (OR = 0.910, p = 0.003) were less likely to complete MyEDCare discharge process. Male patients had
lower odds compared with female (OR = 0.925, p = 0.002). Non-English and nonmarried had a negative impact on access (OR = 0.885,
p = 0.002 and OR = 0.870, p = 0.002). Patients who visited the community ED had decreased odds by 0.937 times
compared with tertiary hospital ED (p = 0.015). Compared with patients who had commercial insurance, patients with Medicaid
(OR = 0.561, p < 0.001), Medicare (OR = 0.625, p < 0.001), and self-pay (OR = 0.622, p < 0.001) had lower odds of access.
Based on our unstructured interviews answered via emails and in person, ED providers
reported increased efficiency applying the new discharge process, particularly for
not having to locate a complete set of discharge papers and then physically deliver
the documents to the right nurse caring for the patient at the time of discharge.
Providers and nurses both cited MyEDCare's benefit in improving patient safety, noting
the verification process with date of birth password mitigated against the possibility
of patients receiving the wrong discharge documents, a HIPAA violation, and recognized
risk of standard paper discharge instructions. During this pilot no patients received
the wrong discharge instructions via MyEDCare. Nursing staff also reported that the
new discharge workflow has improved both the ED discharge process and the coordination
of outpatient care. For example, MyEDCare allowed patients with primary care outside
of the study site network to email their results and follow-up instructions directly
to their providers. Patients who need orthopaedic follow-up appointments noted an
increased benefit for the availability of X-ray reports directly to share with their
orthopaedists. For patient navigators, who typically need access to discharge paperwork
with test results as well as patients' picture IDs and insurance cards, misplaced
discharge paperwork often caused interruptions in this care transition. MyEDCare helped
circumvent this hindrance by eliminating the need for paper discharge paperwork. As
shown in [Table 5], ED-CAHPS scores for MyEDCare patients demonstrated higher than average scores in
the following questions related to nursing care: nurses explain in a way you understand;
Nurses listen carefully; Nurses treat you with respect. No other differences in ED-CAHPS
questions were determined significant.
Table 5
Comparing ED-CAHPS score between MyEDCare and paper discharge
|
Question
|
Completed MyEDCare discharge (N response = 338)
|
Paper-discharge (N response = 928)
|
p-Value
|
|
Before you left, someone ask for follow-up care
|
85.2
|
81.8
|
0.155
|
|
Left ER understanding health problem
|
82.0
|
85.8
|
0.098
|
|
Left ED understanding symptoms
|
81.8
|
87.2
|
0.276
|
|
MD explain in way you understand
|
84.6
|
85.8
|
0.588
|
|
MD listen carefully to you
|
86.9
|
84.5
|
0.061
|
|
MD spend enough time with you
|
71.9
|
74.1
|
0.210
|
|
MD treat you with respect
|
89.2
|
87.9
|
0.435
|
|
Nurses explain in way you understand
|
86.5
|
81.9
|
0.033[a]
|
|
Nurses listen carefully
|
85.4
|
81.9
|
0.022[a]
|
|
Nurses spend enough time with you
|
70.2
|
71.6
|
0.423
|
|
Nurses treat you with respect
|
89.0
|
86.1
|
0.032[a]
|
|
Rate ER
|
82.8
|
81.9
|
0.937
|
|
Recommend ER
|
83.2
|
82.5
|
0.669
|
Abbreviations: ED, emergency department; ER, emergency room; MD, Doctor of Medicine.
a
p-Value < 0.05.
Discussion
Our results demonstrate that patients who were discharged via MyEDCare ED discharge
process had less frequent 72-hour, 9-day, and 30-day unscheduled return ED visits.
On average, patients accessed the online platform twice, demonstrating engagement
with MyEDCare content beyond the ED nurse lead discharge process. Unstructured interviews
with ED staff all reported positive feedback on the new process, including an absence
of patients receiving the wrong discharge instructions, both HIPPA and patient safety
issue occurring in the standard paper-based ED discharge process. Given these findings,
we believe EDs, urgent care facilities, and potentially inpatient hospital services
may consider developing an optional, HIPAA-compliant, smartphone, text-based ED discharge
process, including the transmission of test results. Given recent survey data suggesting
patients may prefer receiving health care information via secure text messages compared
with patient portals, even health care systems with PHR should consider this process.[35]
Multiple variables affect patients' individual discharge processes in a large urban
ED serving a diverse patient population. This study demonstrated that a smartphone,
text-based ED discharge is not feasible for all ED patients: 43% of treat and release
ED patients received the online content, and 27% successfully accessed the online
content, respectively. The 57% of discharged patients who were not enrolled in MyEDCare
reflect the complex community our two urban EDs serve. As part of the gap analysis,
we discovered multiple patient groups for which MyEDCare was not appropriate. They
include chronically ill patients from long-term care facilities without smartphones
(and a formal need for paper discharge documents), and patients from vulnerable sociodemographic
groups such as patient who are illiterate, non-English speaking or cannot afford a
smartphone or the associated carrier data charges. Additional functions of the MyEDCare
platform, such as a chat feature (with providers, care managers, and patient navigators
in the ED), may further enhance post-ED transitions of care in some patient groups
who are excluded from PHR use.
Alternatives to text communication post ED discharge include PHR mobile applications
associated with an EHR. During the time this study was conducted our health system
did not use ED EHR with an interfacing patient portal, but this authorship argues
that text messaging can be an alternative to or complement PHRs. Text messaging enjoys
high consumer interface familiarity and, despite the exponential rise of message apps,
continues to be the most widely adopted and least expensive technological function
on mobile phones; the cost of the average commercial health app is around US $425,000.[36]
[37] “Push” technology delivered without any effort from the individual, text messages
exhibit up to a 98% open rate and a response rate double that of email, phone, or
social media.[38]
[39] While text messages and push notifications from mobile applications are similar
in functionality, in practice texts offer platform independence and lower data plan
requirement. In contrast, PHR account creation and activation barriers may be accentuated
during the ED visit, such as the time and attention required for enrollment, downloading,
and initial navigation.[40] Furthermore, mobile applications require new downloads and push notifications enabled
when devices are changed, whereas changes in phone numbers are not frequent, thus
allowing potential long-term communication.
Several additional opportunities for program refinement were identified during this
pilot study based on findings from the patients who were sent the text message but
could not access the online content. Limitations were predominantly technological,
including incompatibility of some smartphone software required to view PDF documents,
prohibitive cellular carrier data contracts, cellular carrier service dead zones in
the ED, and cell carrier text delays. Optimizing suboptimal cell carrier service in
our EDs increased the number of patients able to receive MyEDCare text messages during
the pilot program.
Patients who completed the MyEDCare discharge demonstrated significantly reduced unscheduled
ED return visits at 72-hour, 9-day, and 30-day time periods, compared with patients
enrolled in MyEDCare but ultimately discharged via standard paper-based discharge
instructions due to an incomplete (failed) MyEDCare ED discharge process. Furthermore,
scheduled return visits (e.g., for suture removal and wound checks) remained unchanged
between the two groups. This suggests that MyEDCare may improve comprehension and
potentially compliance with the post ED care plan, preventing ED return visits.[7] However, similar differences in unscheduled return visits were also observed when
comparing all patients enrolled in MyEDCare (including those with incomplete MyEDCare,
defaulting to standard paper-based discharge) to those with planned standard paper-based
discharge. Given the demographic divergence between these subgroups, these findings
suggests that bias between subgroups may limit conclusions on the impact of MyEDCare
on unplanned ED revisits. Similarly, demographic differences between the subgroups
also limit conclusions regarding the impact of MyEDCare on patient satisfaction. Our
hypothesis is that the higher scores in the nursing domains may be explained by the
nursing-lead “confirmation of completion” process required for MyEDCare discharge.
An additional limitation to the study is that some patients discharged via MyEDCare
requested additional paper copies of relevant information on their ED care (e.g.,
test results). These requests were accommodated by the ED team by also printing out
documents directly from the EHR. Unfortunately, these cases were not captured in our
analysis, such cases were only identified as successfully completing MyEDCare discharge
process.
Patients who accessed MyEDCare were more likely to be married, have commercial insurance,
and be racially White. These findings suggest that MyEDCare was more accessible to
patients from historically privileged and wealthier groups. Similar innovation inequities
in these groups have been identified within the context of growing telehealth and
PHR use.[41]
[42] Future work on MyEDCare should examine barriers related to patient characteristics
and demographics and further iterations of MyEDCare should be multilingual, especially
given the diverse ethnic and linguistic differences amongst ED patients in our catchment
area. It is also important to better understand operational factors associated with
utilization, including the time of day patients interacted with the content, whether
recurrent text messages increased patient engagement. The MyEDCare development team
will also explore video content on the platform, shown to enhance patient engagement
and comprehension and address literacy barriers.[43]
[44]
[45]
[46]
[47]
[48]
[49] Robust conclusions about clinical outcomes related to MyEDCare, such as its impact
on subsequent ED visits and health care trajectories will require further research.
Conclusion
This study reports our pilot program enrolling patients from diverse communities of
an urban city who we attempted to discharge from two EDs via a personal smartphone,
text-based ED discharge process. MyEDCare was found to reduce 72-hour, 9-day, and
30-day unscheduled return ED visits and have a positive impact on patients' perceptions
of ED nursing. As populations become increasingly reliant on smartphones, developing
processes to complement this technological evolution will facilitate the design of
future health care models. Further research would be required to demonstrate the impact
of smartphone, text-based ED discharge on clinical outcomes, patient and staff satisfaction,
as well as on how such technological solutions can be inclusive of vulnerable populations.
Clinical Relevance Statement
Clinical Relevance Statement
Poor comprehension regarding emergency department (ED) care and low compliance with
post-ED care instructions contribute to high ED return rates and potential adverse
events. Exploring the use of a text-based, smartphone ED discharge process is an important
step in technology innovation to improve post-ED transitions of care and patient-centered
outcomes.
Multiple Choice Questions
Multiple Choice Questions
-
When implementing a smartphone-based ED discharge process, which of the following
must have close attention to ensure sufficient patient uptake?
Correct Answer: The correct answer is option c.
-
After implementing a smartphone-based ED discharge process, which of the following
can be measured to evaluate patient satisfaction?
-
ED-CAHPS score
-
72-hour ED return
-
30-day ED return
-
All of the above.
Correct Answer: The correct answer is option d.
