Ronald Jacolbia, BA

Thirty‐six million adults were discharged from US hospitals in 2012, with approximately 45% from medicine service lines.[1, 2] Discharge planning, a key aspect of care for hospitalized patients,[3] should involve the development of a plan to enable the patient to be discharged at the appropriate time and with provision of sufficient postdischarge support and services.[4]

Central to the discharge planning process is an assessment of a patient's readiness for discharge. Readiness is often a provider‐driven process, based on specific clinical and health system benchmarks.[5] However, providers' perception of readiness for discharge does not always correlate with patients' self‐assessments or objective measures of understanding.[6] For example, nurses overestimate patients' readiness for discharge compared to patients' own self‐report.[7] As a result, the need to include the patient perspective is increasingly recognized as an important contributing factor in the discharge planning process.[8, 9]

Current approaches to assessing discharge readiness are typically single assessments. However, these assessments do not take into account the complexity of discharge planning or patients' understanding, or their ability to carry out postacute care tasks.[8] In addition, few models have included assessments of physical stability and functional ability along with measures such as ability to manage self‐care activities at home, coping and social support, or access to health system and community resources.[10, 11]

To address these gaps in the existing literature, we carried out a prospective observational study of daily, patient‐reported, assessments of discharge readiness to better understand patients' perspectives on issues that could impede the transition to home. Using these data, we then sought to determine the prevalence of patient‐reported discharge barriers and the frequency with which they were resolved prior to the day of discharge. We also explored whether problems identified at discharge were associated with 30‐day readmission.

METHODS

RESULTS

DISCUSSION

Assessing discharge readiness highlights an opportunity to engage patients directly in their discharge planning process. However, our prospective study of 163 hospitalized adults revealed that unresolved discharge barriers were common; 90% of patients were discharged with at least 1 issue that might inhibit an effective transition home. The majority of these patients were also discharged home without any support services. In addition, many of the major barriers patients reportedpain, lack of understanding around plans, and ability to provide self‐carewere consistent from admission to discharge, suggesting a missed opportunity to address problems present early in a patient's stay.

Some of the issues our patients described, such as pain; lack of understanding of a recovery plan; and functional, social, and environmental vulnerabilities that impede recovery, have been described in studies using data collected in the postacute time period.[13, 14, 15] Focus on postacute barriers is likely to be of limited clinical utility to assist in any real‐time discharge planning, particularly planning that assesses individual patients' needs and tailors programs and education appropriately. Having said this, consistency between our results and data collected from postdischarge patients again supports broad areas of improvement for health systems.

Persistent gaps in care at discharge may be a result of limited standardization of discharge processes and a lack of engagement in obtaining patient‐reported concerns. Lack of a framework for preparing individual patients for discharge has been recognized as a significant obstacle to effective discharge planning. For example, Hesselink et al.'s qualitative study with almost 200 patients and providers across multiple institutions described how lack of a standard approach to providing discharge planning resulted in gaps in information provision.[16] Similarly, Horwitz et al. described wide variation in discharge practices at a US academic medical center, suggesting lack of a standard approach to identifying patient needs.[14]

Although many transitions of care programs have supported implementation of specific care interventions at a hospital or health system level, there have been surprisingly few studies describing efforts to standardize the assessment of discharge barriers and prospectively engage individual patients.[17] One emblematic study used stakeholder interviews and process mapping to develop a readiness report within their electronic medical record (EMR).[17] Aggregate data from the EMR including orders and discharge plans were coded, extracted, and summarized into a report. The overall goal of the report was to identify progress toward completion of discharge tasks; however, a limitation was that it did not explicitly include patient self‐assessments. Another study by Grimmer et al. describes the development of a patient‐centered discharge checklist that incorporated patients and care concerns.[18] The themes incorporated into this checklist cover many transitional issues; however, outside of the checklist's development, few publications or Web resources describe it in actual use.

Our approach may represent an advance in approaches to engaging patients in discharge planning and preparing patients for leaving the hospital. Although our data do not support efficacy of our daily surveys in terms of improving discharge planning, this initial evaluation provides the framework upon which providers can develop discharge plans that are both standardized in terms of using a structured multidomain communication tool to elicit barriers, as well as patient‐centered and patient‐directed, by using the information collected in the survey tool to initiate tailored discharge planning earlier in the hospital stay. However, our program points out an important limitation of an entirely patient‐initiated program, which is difficulty obtaining truly daily assessments. During this study, we had a single research assistant visit patients as frequently as possible during hospitalization, but even daily visits did not yield complete information on all patients. Although this limitation may in part be due to the fact that our study was a focused pilot of an approach we hope to expand, it also represents the complexity of patient experience in the hospital, where patients are often out of their room for tests, are unable to complete a survey because of problematic symptoms, or simply are unwilling or unable to participate in regular surveys.

Our study has a number of limitations. First, the number of patients in our study overall, and the number who completed at least 2 surveys, was relatively small, limiting the generalizability of the study and our ability to determine the true prevalence of unresolved barriers at discharge. In addition, our selection criteria and response rates have limited our sample in that our final group may not be representative of all patients admitted to our medicine service. The broad exclusion of patients who had physical or psychosocial barriers, and those who were acutely unwell and symptomatic, has the potential to introduce selection bias given the excluded populations are those most at risk of readmission. We also acknowledge that some of the issues that patients' are reporting may be chronic ones. However, given the fact that patients feel these issues, even if chronic, are unaddressed or that they want to talk with their doctor about them, is still a very large potential gap in care and patient engagement.

However, despite these limitations, which seem most likely to produce a cohort that is more likely to be able to participate in our survey, and in turn more likely to participate in their care more broadly, we still observed disappointing resolution of discharge barriers. In addition, our adapted survey instrument, though based on well‐supported conceptual frameworks,[19] has not been extensively tested outside of our hospital setting. Finally, as a single‐center study, our results cannot be generalized to other settings.

Assessing discharge readiness highlights an opportunity to obtain patient self‐reported barriers to discharge. This can facilitate discharge planning that targets individual patient needs. This information also emphasizes potentially fruitful opportunities for improved communication and education activities, potentially if these data are fed back to providers in real time, potentially as part of team‐based dashboards or the context of interdisciplinary team models.

Thirty‐six million adults were discharged from US hospitals in 2012, with approximately 45% from medicine service lines.[1, 2] Discharge planning, a key aspect of care for hospitalized patients,[3] should involve the development of a plan to enable the patient to be discharged at the appropriate time and with provision of sufficient postdischarge support and services.[4]

Central to the discharge planning process is an assessment of a patient's readiness for discharge. Readiness is often a provider‐driven process, based on specific clinical and health system benchmarks.[5] However, providers' perception of readiness for discharge does not always correlate with patients' self‐assessments or objective measures of understanding.[6] For example, nurses overestimate patients' readiness for discharge compared to patients' own self‐report.[7] As a result, the need to include the patient perspective is increasingly recognized as an important contributing factor in the discharge planning process.[8, 9]

Current approaches to assessing discharge readiness are typically single assessments. However, these assessments do not take into account the complexity of discharge planning or patients' understanding, or their ability to carry out postacute care tasks.[8] In addition, few models have included assessments of physical stability and functional ability along with measures such as ability to manage self‐care activities at home, coping and social support, or access to health system and community resources.[10, 11]

To address these gaps in the existing literature, we carried out a prospective observational study of daily, patient‐reported, assessments of discharge readiness to better understand patients' perspectives on issues that could impede the transition to home. Using these data, we then sought to determine the prevalence of patient‐reported discharge barriers and the frequency with which they were resolved prior to the day of discharge. We also explored whether problems identified at discharge were associated with 30‐day readmission.

METHODS

RESULTS

DISCUSSION

Assessing discharge readiness highlights an opportunity to engage patients directly in their discharge planning process. However, our prospective study of 163 hospitalized adults revealed that unresolved discharge barriers were common; 90% of patients were discharged with at least 1 issue that might inhibit an effective transition home. The majority of these patients were also discharged home without any support services. In addition, many of the major barriers patients reportedpain, lack of understanding around plans, and ability to provide self‐carewere consistent from admission to discharge, suggesting a missed opportunity to address problems present early in a patient's stay.

Some of the issues our patients described, such as pain; lack of understanding of a recovery plan; and functional, social, and environmental vulnerabilities that impede recovery, have been described in studies using data collected in the postacute time period.[13, 14, 15] Focus on postacute barriers is likely to be of limited clinical utility to assist in any real‐time discharge planning, particularly planning that assesses individual patients' needs and tailors programs and education appropriately. Having said this, consistency between our results and data collected from postdischarge patients again supports broad areas of improvement for health systems.

Persistent gaps in care at discharge may be a result of limited standardization of discharge processes and a lack of engagement in obtaining patient‐reported concerns. Lack of a framework for preparing individual patients for discharge has been recognized as a significant obstacle to effective discharge planning. For example, Hesselink et al.'s qualitative study with almost 200 patients and providers across multiple institutions described how lack of a standard approach to providing discharge planning resulted in gaps in information provision.[16] Similarly, Horwitz et al. described wide variation in discharge practices at a US academic medical center, suggesting lack of a standard approach to identifying patient needs.[14]

Although many transitions of care programs have supported implementation of specific care interventions at a hospital or health system level, there have been surprisingly few studies describing efforts to standardize the assessment of discharge barriers and prospectively engage individual patients.[17] One emblematic study used stakeholder interviews and process mapping to develop a readiness report within their electronic medical record (EMR).[17] Aggregate data from the EMR including orders and discharge plans were coded, extracted, and summarized into a report. The overall goal of the report was to identify progress toward completion of discharge tasks; however, a limitation was that it did not explicitly include patient self‐assessments. Another study by Grimmer et al. describes the development of a patient‐centered discharge checklist that incorporated patients and care concerns.[18] The themes incorporated into this checklist cover many transitional issues; however, outside of the checklist's development, few publications or Web resources describe it in actual use.

Our approach may represent an advance in approaches to engaging patients in discharge planning and preparing patients for leaving the hospital. Although our data do not support efficacy of our daily surveys in terms of improving discharge planning, this initial evaluation provides the framework upon which providers can develop discharge plans that are both standardized in terms of using a structured multidomain communication tool to elicit barriers, as well as patient‐centered and patient‐directed, by using the information collected in the survey tool to initiate tailored discharge planning earlier in the hospital stay. However, our program points out an important limitation of an entirely patient‐initiated program, which is difficulty obtaining truly daily assessments. During this study, we had a single research assistant visit patients as frequently as possible during hospitalization, but even daily visits did not yield complete information on all patients. Although this limitation may in part be due to the fact that our study was a focused pilot of an approach we hope to expand, it also represents the complexity of patient experience in the hospital, where patients are often out of their room for tests, are unable to complete a survey because of problematic symptoms, or simply are unwilling or unable to participate in regular surveys.

Our study has a number of limitations. First, the number of patients in our study overall, and the number who completed at least 2 surveys, was relatively small, limiting the generalizability of the study and our ability to determine the true prevalence of unresolved barriers at discharge. In addition, our selection criteria and response rates have limited our sample in that our final group may not be representative of all patients admitted to our medicine service. The broad exclusion of patients who had physical or psychosocial barriers, and those who were acutely unwell and symptomatic, has the potential to introduce selection bias given the excluded populations are those most at risk of readmission. We also acknowledge that some of the issues that patients' are reporting may be chronic ones. However, given the fact that patients feel these issues, even if chronic, are unaddressed or that they want to talk with their doctor about them, is still a very large potential gap in care and patient engagement.

However, despite these limitations, which seem most likely to produce a cohort that is more likely to be able to participate in our survey, and in turn more likely to participate in their care more broadly, we still observed disappointing resolution of discharge barriers. In addition, our adapted survey instrument, though based on well‐supported conceptual frameworks,[19] has not been extensively tested outside of our hospital setting. Finally, as a single‐center study, our results cannot be generalized to other settings.

Assessing discharge readiness highlights an opportunity to obtain patient self‐reported barriers to discharge. This can facilitate discharge planning that targets individual patient needs. This information also emphasizes potentially fruitful opportunities for improved communication and education activities, potentially if these data are fed back to providers in real time, potentially as part of team‐based dashboards or the context of interdisciplinary team models.

Thirty‐six million adults were discharged from US hospitals in 2012, with approximately 45% from medicine service lines.[1, 2] Discharge planning, a key aspect of care for hospitalized patients,[3] should involve the development of a plan to enable the patient to be discharged at the appropriate time and with provision of sufficient postdischarge support and services.[4]

Central to the discharge planning process is an assessment of a patient's readiness for discharge. Readiness is often a provider‐driven process, based on specific clinical and health system benchmarks.[5] However, providers' perception of readiness for discharge does not always correlate with patients' self‐assessments or objective measures of understanding.[6] For example, nurses overestimate patients' readiness for discharge compared to patients' own self‐report.[7] As a result, the need to include the patient perspective is increasingly recognized as an important contributing factor in the discharge planning process.[8, 9]

Current approaches to assessing discharge readiness are typically single assessments. However, these assessments do not take into account the complexity of discharge planning or patients' understanding, or their ability to carry out postacute care tasks.[8] In addition, few models have included assessments of physical stability and functional ability along with measures such as ability to manage self‐care activities at home, coping and social support, or access to health system and community resources.[10, 11]

To address these gaps in the existing literature, we carried out a prospective observational study of daily, patient‐reported, assessments of discharge readiness to better understand patients' perspectives on issues that could impede the transition to home. Using these data, we then sought to determine the prevalence of patient‐reported discharge barriers and the frequency with which they were resolved prior to the day of discharge. We also explored whether problems identified at discharge were associated with 30‐day readmission.

METHODS

RESULTS

DISCUSSION

Assessing discharge readiness highlights an opportunity to engage patients directly in their discharge planning process. However, our prospective study of 163 hospitalized adults revealed that unresolved discharge barriers were common; 90% of patients were discharged with at least 1 issue that might inhibit an effective transition home. The majority of these patients were also discharged home without any support services. In addition, many of the major barriers patients reportedpain, lack of understanding around plans, and ability to provide self‐carewere consistent from admission to discharge, suggesting a missed opportunity to address problems present early in a patient's stay.

Some of the issues our patients described, such as pain; lack of understanding of a recovery plan; and functional, social, and environmental vulnerabilities that impede recovery, have been described in studies using data collected in the postacute time period.[13, 14, 15] Focus on postacute barriers is likely to be of limited clinical utility to assist in any real‐time discharge planning, particularly planning that assesses individual patients' needs and tailors programs and education appropriately. Having said this, consistency between our results and data collected from postdischarge patients again supports broad areas of improvement for health systems.

Persistent gaps in care at discharge may be a result of limited standardization of discharge processes and a lack of engagement in obtaining patient‐reported concerns. Lack of a framework for preparing individual patients for discharge has been recognized as a significant obstacle to effective discharge planning. For example, Hesselink et al.'s qualitative study with almost 200 patients and providers across multiple institutions described how lack of a standard approach to providing discharge planning resulted in gaps in information provision.[16] Similarly, Horwitz et al. described wide variation in discharge practices at a US academic medical center, suggesting lack of a standard approach to identifying patient needs.[14]

Although many transitions of care programs have supported implementation of specific care interventions at a hospital or health system level, there have been surprisingly few studies describing efforts to standardize the assessment of discharge barriers and prospectively engage individual patients.[17] One emblematic study used stakeholder interviews and process mapping to develop a readiness report within their electronic medical record (EMR).[17] Aggregate data from the EMR including orders and discharge plans were coded, extracted, and summarized into a report. The overall goal of the report was to identify progress toward completion of discharge tasks; however, a limitation was that it did not explicitly include patient self‐assessments. Another study by Grimmer et al. describes the development of a patient‐centered discharge checklist that incorporated patients and care concerns.[18] The themes incorporated into this checklist cover many transitional issues; however, outside of the checklist's development, few publications or Web resources describe it in actual use.

Our approach may represent an advance in approaches to engaging patients in discharge planning and preparing patients for leaving the hospital. Although our data do not support efficacy of our daily surveys in terms of improving discharge planning, this initial evaluation provides the framework upon which providers can develop discharge plans that are both standardized in terms of using a structured multidomain communication tool to elicit barriers, as well as patient‐centered and patient‐directed, by using the information collected in the survey tool to initiate tailored discharge planning earlier in the hospital stay. However, our program points out an important limitation of an entirely patient‐initiated program, which is difficulty obtaining truly daily assessments. During this study, we had a single research assistant visit patients as frequently as possible during hospitalization, but even daily visits did not yield complete information on all patients. Although this limitation may in part be due to the fact that our study was a focused pilot of an approach we hope to expand, it also represents the complexity of patient experience in the hospital, where patients are often out of their room for tests, are unable to complete a survey because of problematic symptoms, or simply are unwilling or unable to participate in regular surveys.

Our study has a number of limitations. First, the number of patients in our study overall, and the number who completed at least 2 surveys, was relatively small, limiting the generalizability of the study and our ability to determine the true prevalence of unresolved barriers at discharge. In addition, our selection criteria and response rates have limited our sample in that our final group may not be representative of all patients admitted to our medicine service. The broad exclusion of patients who had physical or psychosocial barriers, and those who were acutely unwell and symptomatic, has the potential to introduce selection bias given the excluded populations are those most at risk of readmission. We also acknowledge that some of the issues that patients' are reporting may be chronic ones. However, given the fact that patients feel these issues, even if chronic, are unaddressed or that they want to talk with their doctor about them, is still a very large potential gap in care and patient engagement.

However, despite these limitations, which seem most likely to produce a cohort that is more likely to be able to participate in our survey, and in turn more likely to participate in their care more broadly, we still observed disappointing resolution of discharge barriers. In addition, our adapted survey instrument, though based on well‐supported conceptual frameworks,[19] has not been extensively tested outside of our hospital setting. Finally, as a single‐center study, our results cannot be generalized to other settings.

Assessing discharge readiness highlights an opportunity to obtain patient self‐reported barriers to discharge. This can facilitate discharge planning that targets individual patient needs. This information also emphasizes potentially fruitful opportunities for improved communication and education activities, potentially if these data are fed back to providers in real time, potentially as part of team‐based dashboards or the context of interdisciplinary team models.

BACKGROUND

Many hospitals have initiated intense efforts to improve transitions of care[1] such as discharge coordinators or transition coaches,[2, 3] but use of mobile devices as approaches to add or extend the value of human interventions have been understudied.[4] Additionally, many hospitalized patients experience substantial inactive time between provider visits, tests, and treatments. This time could be used to engage patients in their care through interactive health education modules and by learning to use their PHR to manage medications and postdischarge appointments.

Greater understanding of the advantages and limitations of mobile devices may be important for improving transitions of care and may help leverage existing hospital personnel resources. However, prior studies have focused on healthcare provider uses of tablet computers for medical education,[5] to collect clinical registration data,[6] or to do clinical work (eg, check labs, write notes)[7, 8, 9] primarily in outpatient settings; few studies have focused on patient uses for this technology in hospital settings.[10, 11] To address these knowledge gaps, we conducted a pilot project to explore inpatient satisfaction with bedside tablets and barriers to usability. Additionally, we evaluated use of these devices to deliver 2 specific Web‐based programs: (1) an interactive video to improve inpatient education about hospital safety, and (2) PHR access to promote inpatient engagement in discharge planning.

METHODS

RESULTS

As shown in Table 1, we enrolled 30 patients. Most participants (60%) were aged 40 years or older, and most (87%) owned a mobile device; 70% owned a laptop and 60% owned a smartphone, but few (22%) owned a computer tablet. Most participants accessed the Internet daily, but fewer reported Internet use for health tasks; about half (52%) communicated with a provider, but few refilled a prescription (27%) or scheduled an appointment (21%) online over the last year.

Nearly all participants (90%) were satisfied or very satisfied with their experience using the tablet in the hospital (Figure 1). Most (87%) required 30 minutes or less for basic orientation, and 70% required only 15 minutes or less. Most participants (83%) were able to independently complete an interactive health education module on hospital safety and were highly satisfied with the module. Despite the fact that 73% of participants were first‐time users of our PHR, the majority were able to login and independently access their medication list, verify scheduled appointments, or send a secure message to their primary care provider.

jhm2169-fig-0001-m.png

Participants aged 50 years or older were less likely to complete orientation in 15 minutes or less compared to those under 50 years old (25% vs 79%, P=0.025); however, age was not a significant factor in ability to complete the online health educational module or perform at least 1 essential PHR function. Other demographic features, such as device ownership and daily Internet use, did not correlate with shorter orientation time, educational module completion, or PHR use (data available on request).

Participants also made suggestions for improvement during the debrief interviews. Several suggested applications for entertainment (gaming, magazines, or music) and 2 suggested that all patients should be introduced to their PHR during hospitalization (data available on request). No device software malfunction (eg, device freezes, Internet connection failures), hardware issues (eg, damage from falls, wetness, or repeated disinfectant exposure), or theft or misappropriation were reported by patients or observed by the RAs to date.

DISCUSSION

Our pilot study suggests that tablet‐based access to educational modules and PHRs can increase inpatient engagement in care with high satisfaction and minimal time for orientation. Surprisingly, even older patients and those who might be considered less tech savvy in terms of Internet use and device ownership were equally able to utilize our tablet interventions. Furthermore, we did not experience any hardware issues in the harsh physical environment of inpatient wards. These preliminary findings suggest the potential utility of tablets for clinically meaningful tasks by inpatients with a low rate of technical issues.

From a technical standpoint, our experience suggests several next steps. First, although orientation time was minimal, it might be even less if patients used their own mobile devices because most patients already owned one. This bring your own device (BYOD) approach could also promote postdischarge patient engagement. Second, the flexibility of a BYOD approach raises the question of whether to also allow patients a choice of application‐based versus browser‐based platforms for specific programs such as the PHR and educational video we used. Indeed, although we used a browser‐based approach, several other teams have developed patient‐facing engagement applications (or apps) for mobile devices,[4, 12] and hospitalists could prescribe apps at discharge as a more providers are now doing in outpatient settings.[13] Of course, maximizing flexibility for BYOD and Web‐based versus app‐based approaches would likely increase patient engagement but would come at the cost of more time and effort for hospital providers to vet apps/websites and educate patients about their use. Third, regardless of the devices and programs used, broader engagement of patients, nurses, hospitalists, and other providers will be needed in the future to identify key areas for development to avoid overburdening patients and providers.

From a quality‐improvement perspective, recent literature has considered broad clinical uses for tablets by hospital providers,[14, 15] but our experience suggests more specific opportunities to improve transitions of care though direct patient engagement. Tablets and other mobile devices may help improve discharge education for patients taking high‐risk medications such as warfarin or insulin using interactive educational modules similar to the hospital safety modules we used. Additionally, clinical staff, such as nurses and pharmacists, can be trained to deliver mobile device interventions such as education on high‐risk medications.[16] Ultimately, scale up for our intervention will require that mobile devices and content eventually improve and replace current practices by hospital staff (especially nurses) in a way that streamlines, rather than compounds, current workflow. This could increase efficiency in these discharge tasks and extend contributions of these providers to high‐quality transitions.

Our study has several limitations. First, although this is a pilot study with only 30 patients, it adds needed scale to much smaller (N=58) published feasibility studies of tablet computer use by inpatients.[11, 12] Beyond more robust feasibility testing, our study adds new data about mobile device use for specific clinical tasks in the hospital such as patient education and PHR use. Second, we did not track postdischarge outcomes to test the effects of our intervention on transition care quality; this will be a focus of our future research. Third, we used existing platforms for interactive educational modules and PHR access at our site; participant satisfaction in our study may not generalize to other platforms. Furthermore, most PHR platforms (including ours) are not optimally configured to engage patients during transitions of care, but we plan to integrate existing functions (such as ability to refill medications or change appointments) into discharge education and planning. Finally, we have not engaged caregivers as surrogates for cognitively impaired patients or adapted our platform for non‐English speakers; these are areas for development in our ongoing work. Overall, our pilot results help set the stage to deploy mobile devices for better patient monitoring, engagement, and quality of care in the inpatient setting.[17]

In conclusion, our pilot project demonstrates that tablet computers can be used to improve inpatient education and patient engagement in discharge planning. Inpatients are highly satisfied with the use of tablets to complete health education modules and access their PHR, with minimal time required for patient training and device management by hospital staff. Tablets and other mobile devices have significant potential to improve patients' education and engagement in their hospital care.

BACKGROUND

Many hospitals have initiated intense efforts to improve transitions of care[1] such as discharge coordinators or transition coaches,[2, 3] but use of mobile devices as approaches to add or extend the value of human interventions have been understudied.[4] Additionally, many hospitalized patients experience substantial inactive time between provider visits, tests, and treatments. This time could be used to engage patients in their care through interactive health education modules and by learning to use their PHR to manage medications and postdischarge appointments.

Greater understanding of the advantages and limitations of mobile devices may be important for improving transitions of care and may help leverage existing hospital personnel resources. However, prior studies have focused on healthcare provider uses of tablet computers for medical education,[5] to collect clinical registration data,[6] or to do clinical work (eg, check labs, write notes)[7, 8, 9] primarily in outpatient settings; few studies have focused on patient uses for this technology in hospital settings.[10, 11] To address these knowledge gaps, we conducted a pilot project to explore inpatient satisfaction with bedside tablets and barriers to usability. Additionally, we evaluated use of these devices to deliver 2 specific Web‐based programs: (1) an interactive video to improve inpatient education about hospital safety, and (2) PHR access to promote inpatient engagement in discharge planning.

METHODS

RESULTS

As shown in Table 1, we enrolled 30 patients. Most participants (60%) were aged 40 years or older, and most (87%) owned a mobile device; 70% owned a laptop and 60% owned a smartphone, but few (22%) owned a computer tablet. Most participants accessed the Internet daily, but fewer reported Internet use for health tasks; about half (52%) communicated with a provider, but few refilled a prescription (27%) or scheduled an appointment (21%) online over the last year.

Nearly all participants (90%) were satisfied or very satisfied with their experience using the tablet in the hospital (Figure 1). Most (87%) required 30 minutes or less for basic orientation, and 70% required only 15 minutes or less. Most participants (83%) were able to independently complete an interactive health education module on hospital safety and were highly satisfied with the module. Despite the fact that 73% of participants were first‐time users of our PHR, the majority were able to login and independently access their medication list, verify scheduled appointments, or send a secure message to their primary care provider.

jhm2169-fig-0001-m.png

Participants aged 50 years or older were less likely to complete orientation in 15 minutes or less compared to those under 50 years old (25% vs 79%, P=0.025); however, age was not a significant factor in ability to complete the online health educational module or perform at least 1 essential PHR function. Other demographic features, such as device ownership and daily Internet use, did not correlate with shorter orientation time, educational module completion, or PHR use (data available on request).

Participants also made suggestions for improvement during the debrief interviews. Several suggested applications for entertainment (gaming, magazines, or music) and 2 suggested that all patients should be introduced to their PHR during hospitalization (data available on request). No device software malfunction (eg, device freezes, Internet connection failures), hardware issues (eg, damage from falls, wetness, or repeated disinfectant exposure), or theft or misappropriation were reported by patients or observed by the RAs to date.

DISCUSSION

Our pilot study suggests that tablet‐based access to educational modules and PHRs can increase inpatient engagement in care with high satisfaction and minimal time for orientation. Surprisingly, even older patients and those who might be considered less tech savvy in terms of Internet use and device ownership were equally able to utilize our tablet interventions. Furthermore, we did not experience any hardware issues in the harsh physical environment of inpatient wards. These preliminary findings suggest the potential utility of tablets for clinically meaningful tasks by inpatients with a low rate of technical issues.

From a technical standpoint, our experience suggests several next steps. First, although orientation time was minimal, it might be even less if patients used their own mobile devices because most patients already owned one. This bring your own device (BYOD) approach could also promote postdischarge patient engagement. Second, the flexibility of a BYOD approach raises the question of whether to also allow patients a choice of application‐based versus browser‐based platforms for specific programs such as the PHR and educational video we used. Indeed, although we used a browser‐based approach, several other teams have developed patient‐facing engagement applications (or apps) for mobile devices,[4, 12] and hospitalists could prescribe apps at discharge as a more providers are now doing in outpatient settings.[13] Of course, maximizing flexibility for BYOD and Web‐based versus app‐based approaches would likely increase patient engagement but would come at the cost of more time and effort for hospital providers to vet apps/websites and educate patients about their use. Third, regardless of the devices and programs used, broader engagement of patients, nurses, hospitalists, and other providers will be needed in the future to identify key areas for development to avoid overburdening patients and providers.

From a quality‐improvement perspective, recent literature has considered broad clinical uses for tablets by hospital providers,[14, 15] but our experience suggests more specific opportunities to improve transitions of care though direct patient engagement. Tablets and other mobile devices may help improve discharge education for patients taking high‐risk medications such as warfarin or insulin using interactive educational modules similar to the hospital safety modules we used. Additionally, clinical staff, such as nurses and pharmacists, can be trained to deliver mobile device interventions such as education on high‐risk medications.[16] Ultimately, scale up for our intervention will require that mobile devices and content eventually improve and replace current practices by hospital staff (especially nurses) in a way that streamlines, rather than compounds, current workflow. This could increase efficiency in these discharge tasks and extend contributions of these providers to high‐quality transitions.

Our study has several limitations. First, although this is a pilot study with only 30 patients, it adds needed scale to much smaller (N=58) published feasibility studies of tablet computer use by inpatients.[11, 12] Beyond more robust feasibility testing, our study adds new data about mobile device use for specific clinical tasks in the hospital such as patient education and PHR use. Second, we did not track postdischarge outcomes to test the effects of our intervention on transition care quality; this will be a focus of our future research. Third, we used existing platforms for interactive educational modules and PHR access at our site; participant satisfaction in our study may not generalize to other platforms. Furthermore, most PHR platforms (including ours) are not optimally configured to engage patients during transitions of care, but we plan to integrate existing functions (such as ability to refill medications or change appointments) into discharge education and planning. Finally, we have not engaged caregivers as surrogates for cognitively impaired patients or adapted our platform for non‐English speakers; these are areas for development in our ongoing work. Overall, our pilot results help set the stage to deploy mobile devices for better patient monitoring, engagement, and quality of care in the inpatient setting.[17]

In conclusion, our pilot project demonstrates that tablet computers can be used to improve inpatient education and patient engagement in discharge planning. Inpatients are highly satisfied with the use of tablets to complete health education modules and access their PHR, with minimal time required for patient training and device management by hospital staff. Tablets and other mobile devices have significant potential to improve patients' education and engagement in their hospital care.

BACKGROUND

Many hospitals have initiated intense efforts to improve transitions of care[1] such as discharge coordinators or transition coaches,[2, 3] but use of mobile devices as approaches to add or extend the value of human interventions have been understudied.[4] Additionally, many hospitalized patients experience substantial inactive time between provider visits, tests, and treatments. This time could be used to engage patients in their care through interactive health education modules and by learning to use their PHR to manage medications and postdischarge appointments.

Greater understanding of the advantages and limitations of mobile devices may be important for improving transitions of care and may help leverage existing hospital personnel resources. However, prior studies have focused on healthcare provider uses of tablet computers for medical education,[5] to collect clinical registration data,[6] or to do clinical work (eg, check labs, write notes)[7, 8, 9] primarily in outpatient settings; few studies have focused on patient uses for this technology in hospital settings.[10, 11] To address these knowledge gaps, we conducted a pilot project to explore inpatient satisfaction with bedside tablets and barriers to usability. Additionally, we evaluated use of these devices to deliver 2 specific Web‐based programs: (1) an interactive video to improve inpatient education about hospital safety, and (2) PHR access to promote inpatient engagement in discharge planning.

METHODS

RESULTS

As shown in Table 1, we enrolled 30 patients. Most participants (60%) were aged 40 years or older, and most (87%) owned a mobile device; 70% owned a laptop and 60% owned a smartphone, but few (22%) owned a computer tablet. Most participants accessed the Internet daily, but fewer reported Internet use for health tasks; about half (52%) communicated with a provider, but few refilled a prescription (27%) or scheduled an appointment (21%) online over the last year.

Nearly all participants (90%) were satisfied or very satisfied with their experience using the tablet in the hospital (Figure 1). Most (87%) required 30 minutes or less for basic orientation, and 70% required only 15 minutes or less. Most participants (83%) were able to independently complete an interactive health education module on hospital safety and were highly satisfied with the module. Despite the fact that 73% of participants were first‐time users of our PHR, the majority were able to login and independently access their medication list, verify scheduled appointments, or send a secure message to their primary care provider.

jhm2169-fig-0001-m.png

Participants aged 50 years or older were less likely to complete orientation in 15 minutes or less compared to those under 50 years old (25% vs 79%, P=0.025); however, age was not a significant factor in ability to complete the online health educational module or perform at least 1 essential PHR function. Other demographic features, such as device ownership and daily Internet use, did not correlate with shorter orientation time, educational module completion, or PHR use (data available on request).

Participants also made suggestions for improvement during the debrief interviews. Several suggested applications for entertainment (gaming, magazines, or music) and 2 suggested that all patients should be introduced to their PHR during hospitalization (data available on request). No device software malfunction (eg, device freezes, Internet connection failures), hardware issues (eg, damage from falls, wetness, or repeated disinfectant exposure), or theft or misappropriation were reported by patients or observed by the RAs to date.

DISCUSSION

Our pilot study suggests that tablet‐based access to educational modules and PHRs can increase inpatient engagement in care with high satisfaction and minimal time for orientation. Surprisingly, even older patients and those who might be considered less tech savvy in terms of Internet use and device ownership were equally able to utilize our tablet interventions. Furthermore, we did not experience any hardware issues in the harsh physical environment of inpatient wards. These preliminary findings suggest the potential utility of tablets for clinically meaningful tasks by inpatients with a low rate of technical issues.

From a technical standpoint, our experience suggests several next steps. First, although orientation time was minimal, it might be even less if patients used their own mobile devices because most patients already owned one. This bring your own device (BYOD) approach could also promote postdischarge patient engagement. Second, the flexibility of a BYOD approach raises the question of whether to also allow patients a choice of application‐based versus browser‐based platforms for specific programs such as the PHR and educational video we used. Indeed, although we used a browser‐based approach, several other teams have developed patient‐facing engagement applications (or apps) for mobile devices,[4, 12] and hospitalists could prescribe apps at discharge as a more providers are now doing in outpatient settings.[13] Of course, maximizing flexibility for BYOD and Web‐based versus app‐based approaches would likely increase patient engagement but would come at the cost of more time and effort for hospital providers to vet apps/websites and educate patients about their use. Third, regardless of the devices and programs used, broader engagement of patients, nurses, hospitalists, and other providers will be needed in the future to identify key areas for development to avoid overburdening patients and providers.

From a quality‐improvement perspective, recent literature has considered broad clinical uses for tablets by hospital providers,[14, 15] but our experience suggests more specific opportunities to improve transitions of care though direct patient engagement. Tablets and other mobile devices may help improve discharge education for patients taking high‐risk medications such as warfarin or insulin using interactive educational modules similar to the hospital safety modules we used. Additionally, clinical staff, such as nurses and pharmacists, can be trained to deliver mobile device interventions such as education on high‐risk medications.[16] Ultimately, scale up for our intervention will require that mobile devices and content eventually improve and replace current practices by hospital staff (especially nurses) in a way that streamlines, rather than compounds, current workflow. This could increase efficiency in these discharge tasks and extend contributions of these providers to high‐quality transitions.

Our study has several limitations. First, although this is a pilot study with only 30 patients, it adds needed scale to much smaller (N=58) published feasibility studies of tablet computer use by inpatients.[11, 12] Beyond more robust feasibility testing, our study adds new data about mobile device use for specific clinical tasks in the hospital such as patient education and PHR use. Second, we did not track postdischarge outcomes to test the effects of our intervention on transition care quality; this will be a focus of our future research. Third, we used existing platforms for interactive educational modules and PHR access at our site; participant satisfaction in our study may not generalize to other platforms. Furthermore, most PHR platforms (including ours) are not optimally configured to engage patients during transitions of care, but we plan to integrate existing functions (such as ability to refill medications or change appointments) into discharge education and planning. Finally, we have not engaged caregivers as surrogates for cognitively impaired patients or adapted our platform for non‐English speakers; these are areas for development in our ongoing work. Overall, our pilot results help set the stage to deploy mobile devices for better patient monitoring, engagement, and quality of care in the inpatient setting.[17]

In conclusion, our pilot project demonstrates that tablet computers can be used to improve inpatient education and patient engagement in discharge planning. Inpatients are highly satisfied with the use of tablets to complete health education modules and access their PHR, with minimal time required for patient training and device management by hospital staff. Tablets and other mobile devices have significant potential to improve patients' education and engagement in their hospital care.