Spotlight Case

Recurrent Hypoglycemia: A Care Transition Failure?

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Source and Credits• This presentation is based on the October 2008

AHRQ WebM&M Spotlight Case– See the full article at http://webmm.ahrq.gov – CME credit is available

• Commentary by: Ted Eytan, MD, MS, MPH– Editor, AHRQ WebM&M: Robert Wachter, MD– Managing Editor: Erin Hartman, MS

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Objectives

At the conclusion of this educational activity, participants should be able to:

• Understand the complementary abilities of an Electronic Health Record and a Personal Health Record in promoting safe care

• Understand the value of patient and family involvement throughout the care process, enabled by this technology

• Learn about the impact of changing Internet access across population groups, and new entrants into the personal health record space

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Case: Recurrent Hypoglycemia

A 70-year-old man with type II diabetes and chronic kidney disease was admitted to the hospital after being found unresponsive at home with a blood glucose level of 23. Two days previously, he had been seen at another emergency department (ED) due to symptomatic hypoglycemia. At that time, he was treated and released with instructions to stop his anti-diabetic medications. On this admission, he was resuscitated with IV dextrose and recovered quickly without neurologic complications.

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Case: Recurrent Hypoglycemia (2)

The patient did not speak English. After he became alert, the medical team questioned him via an interpreter, and learned that the patient did not understand that he was supposed to check his blood sugars at home, and did not know the symptoms of hypoglycemia.

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Health Literacy

• In elderly patients, poor health literacy is a significant risk factor for future mortality

• Physicians, nurses, and pharmacists must work to lessen individual patients’ risks

Baker DW, et al. Arch Intern Med. 2007;167:1503-1509.

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Case (cont.): Recurrent Hypoglycemia (3)

On obtaining further history, the medical team learned that the patient had also received multiple samples of oral hypoglycemic (i.e., anti-diabetic) medications from his primary care physician, and was taking them indiscriminately. He was discharged home in good condition and was strictly instructed not to take any anti-diabetic medications.

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Case (cont.): Recurrent Hypoglycemia (4)

Eight days later, the patient was readmitted after again being found unresponsive, this time with a blood sugar of 11. In the interim, he had seen his primary physician, who had restarted a sulfonylurea (a common type of anti-diabetic drug) despite the patient's relatively advanced chronic kidney disease. The patient recovered after a 3-day hospitalization.

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Issues in Present Case

• Case report does not mention whether patient’s primary physician received information about the care and post-discharge plan

• Information technology could have helped to prevent the patient’s multiple ED visits and two hospitalizations

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Discharge Communication

• Most practices in US continue to use paper-based discharge communication systems

• Such systems require that the patient’s record be manually updated after an ED visit or hospitalization

• Discharge processes and forms vary for different health care institutions

• Lack of standardization impedes efforts to transmit information regarding the hospital visit to primary care setting

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Electronic Health Record (EHR)

• “An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one health care organization”

• Definition distinguishes EHR from simple Electronic Medical Record (EMR), since the latter need not span multiple health systems

See Notes for reference.

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How EMR Could Have Helped

• EMR would provide point-of-care decision support to primary MD regarding use of oral hypoglycemic medications in patients with chronic kidney disease

• EMR-generated after-visit summary, given to patient after an ED visit or primary care encounter, would provide additional safety

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How a True EHR Could Have Helped

• Facilitate transition of care from ED to outpatient setting

• In advanced, integrated systems, medication reconciliation can be performed electronically in the ED, reflected instantly in patient’s outpatient record

• This record can be used to facilitate safe care in primary care office

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Shifting Focus to Community

• Today’s interoperable EHR is designed to support practitioner-centric, rather than patient-centric, health system

• Changing locus of control from provider and health care organizations to patients themselves will prove to be most powerful impact of health information technology

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Personal Health Records (PHR)

• Give patients online access to their health information• Health records viewable, managed, and shared by

patients• Personal health records support patient involvement

by giving patients the ability to:– Review after-visit instructions– Search information in their medical record– Confirm medication regimens– Ask questions of health care providers at their convenience

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PHR May Change Practice

• Physicians do not tell patients name of medication being prescribed up to 26% of the time– Computer-generated summary of visit may prompt questions

and change this practice• Family members with access to patient’s medication

record in hospital may become aware of a missed dose– Prompting bedside (rather than conference room or nurses’

station) discussion of medication regimen• Patients with online access may develop enhanced

expectations for timely and accurate delivery of information

See Notes for references.

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Internet Access

• Widespread Internet access will be increasingly important as more health information and communication becomes electronic

• Computer and Internet access for medically underserved populations has been expanding

See Notes for references.

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Innovative Solutions

• Patient-centered health information technology and care systems– One system uses smartcards that allow patients to

exchange personal health information with local care providers and emergency departments

– Another system connects migrant and farm workers to the health system through a personal health record and identification system supported by health promoters

• In both examples, the patient manages privacy and security

See Notes for references.

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Promoting Patient Access

• Certification Commission for Health Information Technology will begin certifying personal health records in 2009, with a focus on privacy, security, and interoperability

• Likely that every patient or health care organization will soon be able to choose a personal health record service or product with confidence

• Research shows that patients want this access, whether insured or uninsured

• Such demand, along with growing national experience with personal health records, will stimulate further innovation

See Notes for references.

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Involving Patients and Families

• Health information technology must be implemented with patient in mind

• Designed with participation ofpatient advisors as well asallied health leaders, nursingleaders, and physician leaders

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Take-Home Points

• An electronic health record facilitates error prevention at the point of care, as a first layer of protection

• Personal health records protect patients through greater involvement in the care process and should be implemented as a part of any inpatient or outpatient health information technology project

• Robust personal health record systems are now available and will continue to flourish with advent of certification process and increasing involvement of established technology vendors