THE CICC INVITES YOU TO A DESIGN EVENT ON PATIENT-ORIENTED DISCHARGE SUMMARIES

We are inviting patients, caregivers, healthcare providers, and designers to attend a design event hosted by the Centre for Innovation in Complex Care. Patients and caregivers will join teams of healthcare providers and designers to work on co-creating patient oriented discharge summaries. What should be on a discharge summary that a patient will take home from the hospital and how should it look?

          When: Thursday, February 13^th, from 1:00 pm to 4:00 pm

         

          Where: Toronto General Hospital, 13^th floor, room 13N 1382

Please email Shoshana Hahn-Goldberg at:

shoshana.hahn-goldberg@uhn.ca

with any questions and to confirm your attendance.

The Good and The Bad of Current Discharge Summaries

At the CICC, we use a "Design Thinking" approach as we carry out our projects. Some interesting research techniques we have used to enrich our understanding of the patient experience at discharge and once they get home are patient experience mapping and cultural probes.

Different from process mapping, patient experience mapping does not only map what happened to the patient during discharge, but also what they were thinking and feeling. What was the experience like for them? What were the pain points?

To learn about what it was like for patients once they got home, we provided them with a journal and a camera to document their experience.

What we learned:

- There are a lot of players in the discharge process and there aren't clearly defined roles.

- Physicians are not well educated on the resources existing in the community.

- Patients are extremely overwhelmed when they get home form the hospital.

- The presence of family and friends makes a big difference.

The discharge summaries currently issued by hospitals are often dense in information, involve heavy use of technical language, and are meant primarily as a tool for hospital to primary care provider communication.

When we reviewed the literature and spoke to patients, we heard both good and bad:

The Good:

- When patients get the summary, they keep it.

- They use it to Google things about their condition or share it with friends.

- They give it to their family doctor. 

- Surgery departments often have very good discharge information packages and they often exist in many languages. They prepare patients for what to expect when they get home.

The Bad:

- Often important information is missing or inconsistent from what happened.

- Often patients do not have a summary given to them before they leave the hospital. If the discharge information is only given verbally, patients do not remember it.

- Often, the patient’s family doctor does not receive the summary in a timely fashion or at all.

- The language used on the summaries is not intelligible to patients.

- Often summaries are put together by someone who is not familiar with the patient.

Above all, patients feel that they would benefit from a ‘patient’ version of the discharge summary. What do you think? What do you do with your discharge summaries? Share your thoughts with us!

Stay tuned to hear more about a design event we are holding on February 13th, where patients and providers will come together to design patient oriented discharge summaries. To get involved, contact Shoshana at shoshana.hahn-goldberg@uhn.ca.

Pictograms From the Developing World

There is a lot to learn from the developing world when it comes to communicating with patients. A lot of the developing world has difficulty with multiple languages and much of the population has low health literacy. In a number of studies, visual aids such as pictograms have been found to aid recall, comprehension and medications adherence which can be effective in enhancing understanding of post discharge instructions, particularly among low-literate patients [1-4]. Given the evidence, countries around the world have adopted pictograms to help improve their discharge processes.

At the Kasturba Hospital in Manipal, India, a group of researchers used pictograms to communicate information about the adverse effects of antiretroviral (ARV) therapy, particularly among the illiterate group. The team designed a set of 20 simple, culturally sensitive pictograms of adverse drug reactions (ADRs) to highly active antiretroviral therapy (HAART). They interviewed 50 hospitalized human immunodeficiency virus (HIV) positive patients on the ARV therapy who ranged from having no schooling to college level education. Results from their study suggest that the use of pictograms can be effective as a counseling tool to improve patient’s knowledge towards the side effects of ARV therapy, particularly among the illiterate and low-literate populations, as well as improve self-efficacy to deal with the challenges associated with adherence to their ARV management [5].

In South Africa, pictograms for prescription medication instructions been have been designed, developed and evaluated in areas with low-literate populations. In one study, the researchers adopted a multistage, iterative process to design a set of local pictograms to communicate medication information among the low-literate Xhosa population in the Eastern Cape--an economically poor region with low literacy rate. The concept of using pictograms to convey medication instructions to patients who could not read was explained. The team surveyed 46 black Xhosa respondents after and found that the use of pictograms were more successful over written text drug labels when communicating medication information. Participants demonstrated lower comprehension of their medication instructions when presented with the text labels. On the other hand, the use of pictograms increased accuracy in the interpretations of the medication instructions and also enhanced better recall among the respondents. The study concluded that the use of pictograms can be effective, particularly if they are developed in collaboration with the target population and cultural influences are taken into consideration [6].

The impacts of low health literacy affecting accurate interpretation and adherence to discharge medication prescriptions were also recognized as major challenges at the Services Hospital in Lahore, Pakistan—where nearly half (48%) of its patients were identified as being illiterate. In the paper, the study team found that an overwhelmingly majority (88% to 95%) of these illiterate patients struggled to interpret the written discharge prescriptions after leaving the hospital. The team redesigned the discharge medication prescription using pictographic images and symbols to convey the information. To evaluate the impacts of the redesigned pictorial discharge prescription, the team conducted a pre/post survey with 100 illiterate patients. Findings showed that the redesigned pictorial prescription instructions demonstrated large relative increases in patients’ comprehension of their medication discharge. Specifically, results indicated that 23%-35% of the participants (depending on the level of counselling given) understood their medication discharge instructions in comparison to 5%-12% of the group when they were given the text written discharge prescription [7].

Here are some existing pictograms of medication and follow up instructions. Let us know what you think of them. Should we use them? Should we change them? Share your thoughts with us!

How can we learn from this? How can we apply this to PODS? Share your thoughts with us!

[1] Dowse R, Ehlers M. Medicine labels incorporating pictograms: do they influence understanding and adherence? Patient Educ Couns. 2005; 58:63-70.

[2] Mansoor LE, Dowse R. Effect of pictograms on readability of patient information materials. Ann Pharmacother. 2003; 37:1003-9.

[3] Morrow DG, Hier CM, Menard WE et al. Icons improve older and younger adults’ comprehension of medication information. J Gerontol B Psychol Sci Soc Sci. 1998; 53B:P240-54.

[4]. Patel V, Eisemon T, Arocha J. Comprehending instructions for using pharmaceutical products in rural Kenya. Instr Sci.1990; 19:71-84.

[5] Dowse R, Ehlers MS. The evaluation of pharmaceutical pictograms in a low-literate South African population. Patient Educ Couns. 2001 Nov; 45(2):87-99.

[6] Rajesh, R, Vidyasagar, S, Varma, M et al. Design And Evaluation of Pictograms for Communicating Information about Adverse Drug reactions to Antiretroviral Therapy in Indian human Immunodeficiency Virus positive patients. Journal of Pharmaceutical and Biomedical Sciences. 2012; 16(10):1-11.

[7] Clayton M, Syed F, Rashid A, Fayyaz U. Improving illiterate patients understanding and adherence to discharge medications. BMJ Qual Improv Report 2012; 1:1 u496.w167. 

Language Barriers, Health Literacy, and Discharge

Language barriers are a reality of the Canadian health care system, particularly in large urban centres such as Toronto, where over 60% use a mother tongue other than English or French at home, and 5% of respective residents report having no knowledge of either of Canada’s official languages. Individuals with language barriers face significant challenges in navigating the health care system, leading to poor self-reported health¹, increased medical errors², poor compliance with therapy and follow-up³ and increased costs⁴. Defined as “the degree to which individuals can obtain, process, and understand basic health information and services needed to make appropriate health decisions⁵,” an estimated 55% of Canadians between the ages of 16 and 65 have low health literacy, and only 12% of those above 65 have adequate health literacy skills. Poor health literacy leads to poor outcomes, especially among the elderly, those with limited education, chronic health diseases, and immigrants with added language barriers.

The period following discharge from a hospital is a vulnerable time for patients. The transition of care responsibilities from the hospital to the primary care provider or from the hospital to the patient frequently results in adverse events, particularly medication errors. Imagine how much worse this can be for patients with language or health literacy barriers. Share your thoughts with us!

If you have been admitted to the hospital in the last year, or have a close family member who was, please consider contacting us and getting involved in the PODS project. Contact Shoshana Hahn-Goldberg at shoshana.hahn-goldberg@uhn.ca

[1] Canadian Institute for Health Information. All-Cause Readmission to Acute Care and Return to the Emergency Department. 2012 June 14. Downloaded May 10 2013 from https://secure.cihi.ca/free_products/Readmission_to_acutecare_en.pdf

[2] Dowse R, Ehlers M. Medicine labels incorporating pictograms: do they influence understanding and adherence? Patient Educ Couns. 2005; 58:63-70.

[3] Mansoor LE, Dowse R. Effect of pictograms on readability of patient information materials. Ann Pharmacother. 2003; 37:1003-9.

[4] Morrow DG, Hier CM, Menard WE et al. Icons improve older and younger adults’ comprehension of medication information. J Gerontol B Psychol Sci Soc Sci. 1998; 53B:P240-54.

[5]. Patel V, Eisemon T, Arocha J. Comprehending instructions for using pharmaceutical products in rural Kenya. Instr Sci.1990; 19:71-84.

What Is the Beyond Words project?

See our project video here.

The Centre for Innovation in Complex Care (CICC), a healthcare innovation hub at the University Health Network has created BEYOND WORDS, a project addressing the patient experience at transition points in and out of the hospital, an issue facing hospitals in Toronto, Ontario, and Canada as a whole.  BEYOND WORDS seeks to improve the communication of information critical to patients and their care. Based on approaches from the developing world, where challenges with literacy and health literacy are high, BEYOND WORDS will use visual communication to bridge the communication divide.

BEYOND WORDS will produce a pictogram-based toolkit consisting of a set of symbols identifying various hospital departments to improve wayfinding on hospital campuses.  The first set of toolkits will be available free of charge to Canadian health care facilities.

BEYOND WORDS will also produce a patient-oriented discharge summary (PODS) designed with and for patients to improve the comprehension of medication and care instructions. The Toronto Central Local Health Integration Network (TC LHIN), recently developed a standardized discharge summary template for the region. The CICC is working with the TC LHIN to include the PODS as a complement to improve hospital-to-patient communication.

If you have questions about BEYOND WORDS or are interested in becoming involved, contact Shoshana Hahn-Goldberg at shoshana.hahn-goldberg@uhn.ca.

ABOUT THE CENTRE FOR INNOVATION IN COMPLEX CARE

The Centre for Innovation in Complex Care (CICC) is a leader in developing, implementing, and evaluating innovative solutions to challenging healthcare issues. The CICC is committed to designing new solutions for healthcare that improve patients’ outcomes and experiences while reducing system cost. As part of the University Health Network (UHN), the CICC is well positioned to leverage the inter-professional expertise of its team that includes physicians, patients, nurses, researchers, engineers, policymakers, and designers. The ultimate goal of all CICC projects is global system impact.

THE BEYOND WORDS ADVISORY TEAM

The Beyond Words Project is being run by the CICC, but it is also being overseen by a multi-disciplinary advisory team. Members include a patient, GIM physicians, an ED physician, pharmacists, designers, engineers, research coordinators, TC LHIN representatives, patient education representatives, and interpretation services representatives.