Instructions for taking medications are difficult enough to understand for the average person, but when low literacy rates and English as a second language join the scenario, patients are likely to fall into a quagmire of non-compliance and confusion.
The 2013 U.S. Census found that 44% of Californians speak a language other than English at home. The 2014 Language Access Ordinance Report indicated that 36% of residents are immigrants; 45% over the age of five speak a language other than English at home — mostly Chinese, Spanish, Tagalog or Russian — and in 13% of households, no one over age 14 speaks English “well” or “very well.”
A program called Meducation from Polyglot Systems is helping to counteract the comprehension problem by explaining to patients how and when to take their drugs.
The Center for Care Innovations, which aims to create innovation hubs in actual patient settings without disrupting workflow, is the impetus behind pilots developed to test Meducation. This year, CCI tried Meducation on for size and found it could fit into the care processes at San Francisco General Hospital; three Northern California health clinics — Petaluma Medical Center, San Mateo Medical Center and West County Health Center — and the San Francisco Department of Public Health.
Although not a CCI hub, Anderson Valley Health Center in Mendocino County uses Meducation as a stand-alone platform for patient education.
The application relies on a calendar with pictograms and icons — a sun for daytime and the moon for nighttime, for example — highlighting each medication prescribed for a patient, explaining how much to take and when and how to administer it; all copy is personalized and written at a fifth grade reading level and translated into 21 languages as needed.
Patients participating in Meducation also receive easy-to-understand, ethnically appropriate consumer medical information on each drug prescribed for them and have access to demonstrations on properly taking drugs and other information on video.
Ray Pedden, who heads up strategy and innovation for CCI, said his organization negotiated a general memorandum of understanding and assisted in contract negotiations between the hubs and Polyglot; tested the interface between Meducation and companies, eClinicalWorks and NextGen, who provide a cloud electronic health record and EHR software, respectively; and developed evaluation metrics.
Once Meducation is up and running, each hub will be responsible for managing and evaluating its use of the program.
“Meducation gives patients all they need to know to be compliant with their medications,” Pedden said. “Education increases the probability of better outcomes.”
If the setting is a hospital, such as SFGH, patients receive Meducation shortly before discharge; clinic patients have access after their exams at which time physicians could use Meducation to ensure patients understand how to take their current drugs and any newly prescribed medications.
SFGH Pilot Shows Improvement in Readmissions
So far, the only completed pilot is the one at SFGH, which included 70 high-risk patients admitted to the hospital. Dave Smith, a clinical pharmacist at SFGH and leader of the hospital’s study, said SFGH chose a cohort of patients who were at risk for readmissions, especially due to medication-related issues; those with a limited understanding of their drugs and health care; and patients with chronic conditions, such as chronic heart disease or chronic obstructive pulmonary disease, or who were taking more than six medications for chronic disease.
The majority of them spoke Spanish, Cantonese and Mandarin.
Twenty-six percent of patients receiving standard medication instructions and counseling at the time of discharge were readmitted to the hospital within 30 days, while those who received counseling from a pharmacist and used Meducation returned to the hospital only 8% of the time, indicating a 70% improvement.
“While we hypothesized that the group receiving pharmacist counseling and the Meducation instructions would have fewer readmissions than the comparison group, we were quite surprised by the magnitude of the difference,” said Michelle Schneidermann, a physician and professor of clinical medicine at UC-San Francisco and SFGH. “Given the study limitations, I would recommend continued evaluation before promising the end-user similar results.
“Most hospitals and health systems are unable to deliver medication instructions tailored to patients with limited health literacy and/or limited English proficiency, but Meducation gives us the capacity to bridge this gap and provide safe and person-centered care and transitions of care for our patients,” Schneidermann said.
SFGH is currently working on identifying an operational “definition” for high-risk patients and high-risk medications with a plan to offer Meducation, bundled with nursing or pharmacist education, to patients who meet the definition, she said.
“We are also exploring the feasibility of offering Meducation in our outpatient clinics to enhance continuity and create a more streamlined and effective care experience for our high-risk patients and their care providers,” she explained.
Smith said that limited staffing for the pilot presented the biggest challenge. In addition, SFGH has not yet been able to integrate the Meducation software into its EHR, providing a workflow challenge, Schneidermann said.
Bay Area Medical Clinics To Evaluate Meducation
The San Mateo County Health System plans to launch a Meducation pilot in its clinics by the end of the year, said Michael Aratow, chief medical information officer for the system and the lead for programs initiated under the San Mateo Medical Center’s innovation hub. Ninety percent of its patient population are Medicaid beneficiaries, and they primarily speak Spanish, Mandarin, Cantonese, Tagalog, Arabic and Portuguese.
He said the pilot will include 2,500 patients and expects outcomes to be operational — saving staff time by requiring fewer explanations of drugs by practitioners because Meducation would provide clinics with written drug summaries for the first time. Aratow also foresees increased patient satisfaction but said that clinical outcomes, such as fewer doctor visits and hospital admissions, will come later.
“If we have more compliance, we will have healthier patients and hopefully realize savings,” he added.
As for challenges, Aratow said it is more difficult, complicated and takes more time to innovate in an organization while it is operating on a daily basis.
Petaluma Medical Center, a community health center, has conducted a pre-pilot, testing the Meducation interface with its EHR. Danielle Oryn, chief medical information officer for the center, anticipates that the real pilot will begin in January and focus on one clinical care team of four physicians, seven providers and four nurse practitioners or physician assistants and the patients it sees on an average day.
Oryn said that Petaluma Medical Center’s population is 45% Hispanic, and one-third is better served in a language other than English. Currently, drug information is only in English, while care summaries and standard forms are in Spanish and English.
While she doesn’t expect that Meducation will save practitioners any time, she hopes to see increased safety and patient satisfaction and fewer admissions, as well as drug information that low-literacy patients find easier to read and understand.
Meducation Falls in Place With Legislation
Meducation aligns with recently passed legislation that requires pharmacists to provide either their own translations or use the state Board of Pharmacy’s 15 standardized translations for directions such as “take one pill at bedtime” or “take one pill in the morning.” The board has translated instructions into Chinese, Korean, Russian, Spanish and Vietnamese. Besides California, New York is the only other state that has passed a similar law.
Previously, pharmacists were required only to provide verbal interpretation over the phone. “Pharmacy services play a central role in modern medicine, and language skills should never be a cause of complications or death,” Assembly member Phil Ting (D-San Francisco), sponsor of the bill, AB 1073, said in a statement.
With a reduction in readmissions as a key objective of Meducation, the application could benefit hospitals in their efforts to comply with readmission standards set by CMS. If rates during a 30-day period exceed the national average for a set of patients with the same conditions, hospitals would receive a penalty of 3% of their base inpatient claims.
Cary Sanders, director of policy analysis for the California Pan-Ethnic Health Network, said Meducation could serve as a tool to put culturally appropriate information into the hands of consumers with low literacy, enabling better access to medication instructions, while improving both the management of care outside of a hospital setting and communication with doctors.