Steven M. Handler

This paper proposes an approach to assess digital health readiness in clinical settings to understand how prepared, experienced, and equipped individual people are to participate in digital health activities. Existing digital health literacy and telehealth prediction tools exist but do not assess technological aptitude for particular tasks or incorporate available electronic health record data to improve efficiency and efficacy. As such, we propose a multidomain digital health readiness assessment that incorporates a person’s stated goals and motivations for use of digital health, a focused digital health literacy assessment, passively collected data from the electronic health record, and a focused aptitude assessment for critical skills needed to achieve a person’s goals. This combination of elements should allow for easy integration into clinical workflows and make the assessment as actionable as possible for health care providers and in-clinic digital health navigators. Digital health readiness profiles could be used to match individuals with support interventions to promote the use of digital tools like telehealth, mobile apps, and remote monitoring, especially for those who are motivated but do not have adequate experience. Moreover, while effective and holistic digital health readiness assessments could contribute to increased use and greater equity in digital health engagement, they must also be designed with inclusivity in mind to avoid worsening known disparities in digital health care.

UNSTRUCTURED This paper proposes an approach to assess digital health readiness in clinical settings to understand how prepared, experienced, and equipped individual people are to participate in digital health activities. Existing digital health literacy and telehealth prediction tools exist but do not assess technological aptitude for particular tasks or incorporate available electronic health record data to improve efficiency and efficacy. As such, we propose a multidomain digital health readiness assessment that incorporates a person’s stated goals and motivations for use of digital health, a focused digital health literacy assessment, passively collected data from the electronic health record, and a focused aptitude assessment for critical skills needed to achieve a person’s goals. This combination of elements should allow for easy integration into clinical workflows and make the assessment as actionable as possible for health care providers and in-clinic digital health navigators. Digital health readiness profiles could be used to match individuals with support interventions to promote the use of digital tools like telehealth, mobile apps, and remote monitoring, especially for those who are motivated but do not have adequate experience. Moreover, while effective and holistic digital health readiness assessments could contribute to increased use and greater equity in digital health engagement, they must also be designed with inclusivity in mind to avoid worsening known disparities in digital health care.

Background Inappropriate polypharmacy, prevalent among older patients, is associated with substantial harms. Objective To develop measures of high-risk polypharmacy and pilot test novel electronic health record (EHR)-based nudges grounded in behavioral science to promote deprescribing. Design We developed and validated seven measures, then conducted a three-arm pilot from February to May 2019. Participants Validation used data from 78,880 patients from a single large health system. Six physicians were pre-pilot test environment users. Sixty-nine physicians participated in the pilot. Main Measures Rate of high-risk polypharmacy among patients aged 65 years or older. High-risk polypharmacy was defined as being prescribed ≥5 medications and satisfying ≥1 of the following high-risk criteria: drugs that increase fall risk among patients with fall history; drug-drug interactions that increase fall risk; thiazolidinedione, NSAID, or non-dihydropyridine calcium channel blocker in heart failure; and glyburide, glimepiride, or NSAID in chronic kidney disease. Interventions Physicians received EHR alerts when renewing or prescribing certain high-risk medications when criteria were met. One practice received a “commitment nudge” that offered a chance to commit to addressing high-risk polypharmacy at the next visit. One practice received a “justification nudge” that asked for a reason when high-risk polypharmacy was present. One practice received both. Key Results Among 55,107 patients 65 and older prescribed 5 or more medications, 6256 (7.9%) had one or more high-risk criteria. During the pilot, the mean (SD) number of nudges per physician per week was 1.7 (0.4) for commitment, 0.8 (0.5) for justification, and 1.9 (0.5) for both interventions. Physicians requested to be reminded to address high-risk polypharmacy for 236/833 (28.3%) of the commitment nudges and acknowledged 441 of 460 (95.9%) of justification nudges, providing a text response for 187 (40.7%). Conclusions EHR-based measures and nudges addressing high-risk polypharmacy were feasible to develop and implement, and warrant further testing.

Adverse events pose serious risk to persons older than 65 years (older adults) in the immediate posthospitalization period. An adverse event is a harm or injury resulting from medical care, including the failure to provide needed care.¹ Given their advanced age and coexistent disability (cognitive, physical, or both), residents of long-term care (LTC) facilities are especially at risk for adverse events after hospital discharge.² While hospitalized, residents often suffer malnutrition through illness and purposeful fasting in preparation for surgery or other procedures. Change in familiar surroundings, disruption of sleep, and receipt of central nervous system–acting agents can lead to delirium. Lack of activity and walking leads to deconditioning. In addition, medication is changed in up to 40% of residents.³ The combination of these factors may increase the risk for adverse events, including falls with injury, pressure ulcers, health care–acquired infections, and adverse drug events, during the posthospitalization period.

Purpose: In this article we describe a novel required longitudinal experience focused on deprescribing designed for postgraduate year 2 (PGY2) geriatric pharmacy residents. This experience was embedded within a clinical pharmacist–driven deprescribing service. Insights on challenges faced and benefits gained during the first offering are also highlighted. Summary: Through collaboration with the University of Pittsburgh School of Pharmacy (UPMC) Palliative and Supportive Institute and the UPMC St. Margaret PGY2 geriatric pharmacy residency program, a year-long required deprescribing-focused experience was developed and executed. The experience was aligned with the American Society of Health-System Pharmacists’ standard goals and objectives and was designed to focus and evaluate 3 skills necessary for all pharmacy practitioners: empathy, critical thinking, and communication. There is a need for proactive deprescribing initiatives to reduce the unnecessary burden and cost associated with potentially inappropriate medications for older patients. Focused deprescribing experiences can better equip pharmacist learners with the ability to lead these initiatives. Conclusion: A required longitudinal deprescribing-focused experience can provide PGY2 geriatric pharmacy residents with opportunities to practice empathy, critical thinking, and communication beyond those typically offered in a residency program.

OBJECTIVE: Potentially inappropriate medications carry significant burden and costs to nursing facility residents and health systems. The goal of this study was to survey nursing facility providers from across the United States to describe the current utilization of deprescribing, and perceptions and desired components of a deprescribing program, in nursing facilities to reduce potentially inappropriate medications. DESIGN/SETTING/PARTICIPANTS/MEASUREMENT: We surveyed health care providers who attended the 2017 AMDA—The Society for Post-Acute and Long-Term Care Medicine Annual Conference—in Phoenix, Arizona. Returned surveys were entered into an electronic database from paper copies. Survey responses were summarized using descriptive statistics. RESULTS: Of the 1,431 conference attendees, 637 surveys were returned for a 45% response rate. Most respondents were physicians (n = 563, 88%). Respondents indicated a strong agreement with the potential for deprescribing to reduce cost to residents and nursing administration time and burden, while disagreeing that deprescribing may be depersonalizing. Respondents indicated clear preference for deprescribing programs to target medications that are no longer indicated and are "high risk," and that such programs should include discussions with the resident. Respondents also agreed that deprescribing programs are successful if the resident, or the resident's family and/or caregivers, reports an improvement in quality of life. CONCLUSION: Among respondents there was a high degree of confidence in the potential impact of deprescribing initiatives, as well as a broad consensus of desired components. This information may increase consultant pharmacist engagement and drive future proactive deprescribing initiatives.

Background: Nursing homes (NHs) provide care to a complex patient population and face the ongoing challenge of meeting resident needs for specialty care. A NH telemedicine care model could improve access to remote specialty providers. Introduction: Little is known about provider interest in telemedicine for specialty consults in the NH setting. The goal of this study was to survey a national sample of NH physicians and advanced practice providers to document their views on telemedicine for providing specialty consults in the NH. Materials and Methods: We surveyed physician and advanced practice providers who attended the 2016 AMDA—The Society for Post-Acute and Long-Term Care Medicine Annual Conference about their likelihood of referral to and perceptions of a telemedicine program for providing specialty consults in the NH. Results: We received surveys from 524 of the 1,274 conference attendees for a 41.1% response rate. Respondents expressed confidence in the ability of telemedicine to fill existing service gaps and provide appropriate, timelier care. Providers showed the highest level of interest in telemedicine for dermatology, geriatric psychiatry, and infectious disease. Only 13% of respondents indicated that telemedicine was available for use in one of their facilities. Discussion: There appears to be unmet demand for telemedicine in NHs for providing specialty consults to residents. Conclusions: The responses of NH providers suggest support for the concept of telemedicine as a modality of care that can be used to offer specialty consults to NH residents.