eHealth Intervention for Trauma Patients in Transitional Care
Transitional care is, “a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location (Coleman, 2003).” While the term can refer to transitions at all points in the healthcare system, for the purposes of this paper we will be focusing on transitions surrounding the emergency department (ED). 81.8% of unscheduled hospital admissions come through the ED, making it a good candidate to impact health outcomes (Most Unscheduled Hospital Admissions Now Come Through ER, 2013).
Transitional care is an urgent public health problem for six primary reasons. First, and perhaps most obviously, poor transition care generally leads to poor health outcomes for the patient (Kessler, 2013). Second, there are a great many medication errors made during this changeover (Manias, 2014). Third, poor transitional care results in poor communication and coordination across the board. Fourth, this poor communication can result in non-adherence to follow-up care. Fifth, the quality of transitional care impacts patient customer satisfaction. And finally, re-admissions to the ED in America costs US$15 billion annually (Moreno, 2013).
An estimated 66% of medication errors occur during transitional care costing approximately US$4 billion each year (Moreno, 2013). One third of Medicare beneficiaries are readmitted to the hospital within 90 days from being discharged (Naylor, 2011). While studies have been done on the cost savings possible from intervention at this care point, many of the models are not comprehensive (Saleh, 2012). Still, it is likely that progress in this area could result in significant healthcare improvements.
The target population of the proposed eHealth intervention will be patients who have suffered traumatic injury and are being discharged from the ED to transition into specialist care and/or physical therapy. Traumatic will be defined as any patient with an Injury Severity Score (ISS) of 15 or higher. Patients will only be considered good candidates for intervention if they are classified as Low Risk Discharge or Moderate Risk Discharge on the Island Peer Review Organization (IPRO) Discharge Criteria Assessment. See Appendix D.
The main information and support needs include patient care information, care coordination, pain medication management, trauma support, and actual care support. Assuming that sufficient progress can be made with physical rehabilitation, the main barriers to change for this population are information overload, lack of care coordination, pain, the inability to cope with the after effects of trauma, and lack of care providers. Challenges that would prevent them from changing their behavior could include pre-existing psychological factors, lack of transportation, language barriers, health literacy barriers, lack of sufficient health insurance, and lack of ability to pay for care not covered by insurance with private funds.
Some of these factors are outside the scope an eHealth intervention, although as with any systems’ development, future versions may find creative ways to approach previously unaddressed problems. For example, Uber is a new company that now provides a transportation option for people who might find it challenging to travel to a healthcare appointment. Similarly, language translation software may become advanced enough that language barriers will no longer be an issue.
Review of the Literature
One of the most important factors in an eHealth intervention is that the patient has access to the information they need within the privacy of their own home. The ED is a stressful environment for patients and providers alike. Some patients may be intimidated by physicians, others may have limited health or language literacy to which they are not willing to admit, patients may be cognitively impaired due to pain and/or medication, and caregivers often do not have the time to fully explain care guidelines (Samuels-Kalow, Stack, & Porter, 2011). While information should be supplied in the hospital setting, information provision needs to be repeated and reinforced for maximum retention and comprehension (Saidinejad & Zorc, 2014).
Another issue raised in the body of literature emphasizes how integrated the healthcare system is. On the one hand, it is vital to be specific when designing effective eHealth interventions. On the other hand, if your design doesn’t interface properly with the large system, it may fail. Each intervention must strike the right balance to serve enough patients to be competitive, but not so many that it is too general to be useful.
For example, when looking at ways to properly construct these interfaces, it is key to see how other actors in the healthcare system are defining their terms. Medical students qualify on a series of metrics called Milestones & Entrustable Professional Activities (EPA) before becoming residents. These EPAs have been mapped to transitional care and then applied to transitional care training models (Meade, Todd, & Walsh, 2015). Reviewing the list of activities provides a vocabulary for how residents are trained to define transitional success. Therefore, the EPAs should probably be studied to ensure that a doctor’s goals in the transitional care space do not conflict with the patient’s eHealth structured goals.
The literature also emphasizes the role of the patient in providing input to the design process (Buckley et al., 2013). An effective intervention should cover patients from the beginning of the transitional care process, when they first receive their ED discharge instructions. Patients have been shown to report satisfaction with the discharge process, but then exhibit insufficient understanding of salient facts (Gignon, 2014). If patients are to understand the information being shared with them, they should have a role in designing the system that will help them with comprehension and recall (Engel, 2009).
Another point made in the literature is the importance of graphics in the interventions (Samuels-Kalow, Stack, & Porter, 2011). Even if people do not have English or health literacy challenges, we live in an increasingly visual world where people are used to processing information through videos, photos, diagrams, and many other types of visualizations. Particularly when dealing with the human body, graphics are often quite a bit easier to process than medical terms. The two should be used in combination, to increase the chances that information will be accurately understood and retained.
When studying online health information platforms, such as Patients Like Me or SuperBetter, the designers have chosen to use bright colors and inspirational visuals (SuperBetter, 2012). This is meant to draw the user back in and make them feel hopeful about topics that can be challenging and demoralizing. In much the same way as the Jawbone Up is designed to be beautiful and stylish, any eHealth intervention should do the same (Jawbone, 2015). Patients certainly should want to come back to the platform because it is useful for their life, but at the same time technology should always be a pleasure to use. It should inspire both daily action and product loyalty
Areas for Further Research
Further research should be done on the right mix of technology in the transitional care space. On the one hand, some patients may not have ready access to computers and internet access in their home environment. Cellular phone use is ever-increasing, but the functionality on even a smartphone is generally less robust than a laptop or desktop. Should hospitals be investing in onsite technology platforms so that patients can be introduced and trained to use the eHealth intervention prior to leaving the facility? Should this type of investment be replacing the popular hospital kiosk?
Perhaps removing the now ubiquitous television monitor and replacing it with personalized tablets would provide entertainment, distraction, and an eHealth intervention platform. Cost benefit research should be done to ascertain if removing televisions would pay for tablets. It is unclear why hospitals continue to add to the noise level by placing televisions in public spaces. Many people are in healthcare settings because they have a health problem that is causing them stress and making them feel that they lack control. Then they are put in a noisy environment where they usually do not have control over the information input from the television, and are forced to wait in that space to be called. Airlines would not dream of forcing passengers to listen to the same unescapable TV in their planes, so why do we continue this pernicious practice in hospitals?
Another area of research that should be explored is the development of awareness computing for the consumer (Monegain, 2014). This technology is being utilized for clinicians, but it has potentials for patients as well. If the information system knew where the patient was, what doctor they were seeing, what caregiver was present, etc., then it could provide the same personalized dashboard configuration being developed for healthcare providers. This ease of use would likely increase engagement.
The potential significance of this eHealth intervention is to empower transitional care patients who have suffered trauma to take control of their recovery process within a framework that integrates physical and psychological facets of healing. One critical component necessary for trauma patient progress is the ability to maintain hope (Warwick, 2012.) There are many factors over which the patient has no control. These include the attitudes of healthcare providers, the availability or usefulness of social support, or even access to quality care. eHealth intervention can help patients focus on those elements they have control over, thereby assisting them in creating a personal reality that is useful to their improvement (Gallagher, 2009).
Naylor’s 2011 review of effective transitional interventions identified the main components that reduced readmission for all causes through a 12-month study period (Naylor, 2011). These included the following features:
- Comprehensive discharge planning
- Follow-up interventions
- Patient goal setting
- Caregiver goal setting
- Individualized care planning
- Educational and behavioral strategies
- Clinical management
Nugent listed six factors that encourage resilience in trauma victims (Nugent, 2014). They were:
- Cognitive flexibility
- Active coping skills
- Maintaining a supportive social network
- Attending to one’s physical well-being
- Embracing a personal moral compass
This eHealth intervention will emphasize integrating the physical and psychological transitional care of patients who have experienced trauma. Therefore, it will blend these factors. These two sources are being used for their broad analysis of expert opinion. Naylor’s original search set for key terms (transitional care, readmissions, discharge, and combinations of these) returned 587 articles, of which 21 were selected for analysis (Naylor, 2011). Nugent’s factors were drawn from a report on the 2013 annual meeting of “The International Society for Traumatic Stress Studies (Nugent, 2013).”
There are four main components to this proposed eHealth intervention; a web portal, a tablet app, a mobile phone app, and a Jawbone Up integration app. The web portal and tablet both provide all the functionality of the intervention, while the mobile app will provide basic information that the patient can reference. The Jawbone Up integration app allows the Up data to be integrated into the intervention physical goals section, including it’s exercise, nutrition, and basic mood features, allowing instant feedback on measurable metrics.
This eHealth intervention will be marketed toward the target population i.e. patients who have suffered traumatic injury and are being discharged from the ED to transition into specialist care and/or physical therapy. Consequently, marketing will be focused on two general avenues; healthcare providers and trauma therapists and support groups. Patients are likely to take the recommendation of an authority figure when they are first brought into the ED for treatment and are in a vulnerable position. Similarly, those who seek additional aid for the psychological effects of their trauma can be encouraged to attend to both their mental and physical health as part of an overall treatment plan.
Patients who have experienced trauma generally feel out of control (National Crime Victims Research and Treatment Center, n.d.). This is typically an unpleasant feeling, which is one reason why people who have experienced trauma will self-medicate to reduce both the psychological and physical pain (Mayo Clinic, 2015). Therefore, persuasive features should focus on embedding the intervention within a model of regaining control and mastery. Some possible components of this could include allowing the patient to create a set of baseline conditions from which to compare future progress, providing graphics to automatically chart progress, and including checklists to encourage feelings of accomplishment and self-efficacy (Fogg, 2003).
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