Virtual Continuity and its Impact on Complex Hospitalized Patients' Care

Communication between physicians of hospitalized patients and their primary care providers (PCPs) is often suboptimal. Hospital-based information systems can improve communication by automating information transfer between these two groups. This project enhanced MedTrak, the information system used by the University of Pittsburgh Medical Center (UPMC), with an intervention called Virtual Continuity. As initially envisioned, Virtual Continuity would provide automated real-time notification and alerts for patients undergoing transitions in care and allow PCPs to obtain current electronic medical records (EMR) and communicate with hospital physicians from a remote location.

The specific aims of this project were to:

• Augment the present system of PCP notification through the development and use of electronic EMR links to allow Virtual Continuity for the PCP. 
• Measure differences in patient care safety and quality between PCPs receiving Virtual Continuity versus usual communication in a pre-post study. 
• Evaluate the impact of Virtual Continuity. 

The project used an expert panel of PCPs to inform the development of communication tools. A questionnaire was developed based on candidate items from the published literature on hospital and PCP communication, communication on medication changes made during hospitalizations, and post-hospitalization care planning.

A two-round modified Delphi survey with the experts was conducted via the Internet. This process showed that PCPs have definite preferences about the type of information they receive and when they receive it, which was not previously well characterized. They also wanted concise information about key findings, medication reconciliation, and followup plans, at the start and finish of hospital stays. PCPs were interested in receiving information about their patients’ emergency department (ED) visits—an area where present systems are frequently inadequate.

Following implementation of the tools, a pre- post-intervention study was conducted utilizing data from the EMR to evaluate the primary outcome of discharge medication errors, and on the secondary outcomes of 30-day rates of re-hospitalization, ED visits, and PCP followup visits. There was a statistically significant decrease in medication errors even when adjusted for age, sex, and the modified Elixhauser comorbidity index score. However, errors that were considered clinically significant—those leading to death, permanent or temporary disability, prolonged hospital stay, readmission, or the need for additional treatment or monitoring to protect the patient from harm—were rare and not significantly different between groups. There was no significant difference seen in PCP followup visits and ED visits at 30 days, or in 30-day readmission or death rates.

The pre-post study took the place of a planned randomized controlled trial, and thus the impact of Virtual Continuity, the third specific aim, was not able to be evaluated. The project succeeded in identifying PCP preferences for needed communication tools and demonstrating that discharge medication errors, the study’s primary outcome, were significantly decreased by a set of automated communication tools designed to update PCPs on their hospitalized patients who were under the care of a hospital physician.