Virtual Patient Advocate to Reduce Ambulatory Adverse Drug Events

The transition process from the hospital to the ambulatory setting is non-standardized and frequently poor in quality. One-in-five hospital discharges is complicated by an adverse event within 30 days, often leading to an emergency department visit or re-hospitalization. Nationally, about 25 percent of hospitalized patients are readmitted within 90 days. Many readmissions stem from errors that can be directly attributed to the discontinuity and fragmentation of care at discharge.

This project developed a post-hospital system to address these issues. In prior AHRQ-funded studies (UC1 HS 014289 and U18 HS 015905), the project team developed a paper-based tool, the After Hospital Care Plan (AHCP), to deliver the Re-Engineered Hospital Discharge (RED), a set of recommended activities to be performed at the time of discharge. Subsequently, in order to make the AHCP electronically available, a virtual patient advocate (VPA) named “Louise” was developed. This computerized animated character emulates the face-to-face conversational behavior of an empathic provider.

This project adapted and tested Louise to interact with patients after hospital discharge in order to address the problems of discontinuity and fragmentation of care that occur in the transition from the hospital to the ambulatory setting. The “post-hospital Louise” system educates patients on self-care and medication use, assesses patient understanding and adherence to medications and appointments, and monitors for adverse events in the days after discharge.

The specific aims of this project were to:

• Program the VPA, a computer-based, interactive, animated character, to offer patients with limited health literacy or health education advice on self-care and medication use during the transition from hospital to ambulatory care. 
• Design and implement an ambulatory care plan using the VPA to educate the patient and respond to questions. 
• Evaluate the intervention in the ambulatory setting. 
• Build a robust dissemination program that will introduce this system into a health care system that is a member of a national test bed. 

The project team developed and programmed the post-hospital Louise system for use by patients in the post-discharge period. The system was pre-tested with 13 patients who had recently been hospitalized, and then revised based on this testing. Analysis of pre-testing system interactions and interviews showed that patients thought the system was helpful and easy to use.

The system was evaluated with a randomized controlled trial (RCT). The control group received typical care for discharge, and a post-discharge visit within 2 weeks. The intervention group received the RED, which included post-hospital Louise interactions between discharge and the first post-discharge visit. Of the 24 participants in the intervention group, four used the system post-discharge. The study showed that the system educates on self-care and medication use; assesses, monitors, and promotes patient understanding and adherence to medications and appointments; and monitors and reports adverse events. The project team concluded that the post-hospital Louise system has great potential to be part of the health care system. Upcoming efforts will focus on a large-scale RCT to examine statistical significance in reduction in adverse drug events between those who use the post-hospital Louise system and those who do not. The larger sample size will support more in-depth data analysis, including stratification of the sample by health literacy status.