Discharge instructions provide critical information for patients to manage their own care. Such instructions are required as core measures to meet accreditation and public reporting requirements by the Centers for Medicare and Medicaid Services and the Joint Commission on Accreditation of Healthcare Organizations. However, studies show that many patients do not fully understand the instructions they receive and that this lack of comprehension reduces patient satisfaction and compliance. Other factors make understanding and remembering instructions challenging for patients: physical and emotional distress, low health literacy level, lack of motivation, and environmental distractions. Since these other factors cannot be eliminated at the time of discharge, researchers and clinicians explore various strategies to make the instructions more understandable. In practice, nurses may provide explanations in lay-friendly terms and draw figures and tables. Studies have shown that text simplification and pictograph enhancement are helpful and pictographs were especially beneficial for low-literacy patients. In this project we will focus on pictograph enhancement. The benefit of pictographs has been demonstrated in numerous studies. However, several problems inhibit the use of pictographs in discharge instructions: (1) manually enhancing patient-specific instructions with pictographs is prohibitively time consuming;(2) there exists no standard pictographic language for patient communication, and (3) there has been limited research on how to systematically develop and evaluate pictographs for patient communication. As a result, patient-specific discharge instructions rarely include pictographs and remain difficult for patients to understand. To solve this problem, we will create a patient-oriented pictographic language and develop a system to automatically enhance free-text instructions with pictographs. We will focus on the domain of gynecologic oncology. Our overall goal is to improve patient comprehension, satisfaction and adherence. Specifically, we will: (1) create a pictographic vocabulary and grammar for discharge instructions, using systematic text analysis, pictograph design, and validation methods;(2) develop an automated pictograph-enhancement system through information extraction and pictograph generation;and (3) evaluate the safety and benefits of automated pictograph enhancement. We will test the system's safety on healthy volunteers. The impact on patient understanding, patient satisfaction, and nurse satisfaction will be assessed in a RCT with patients at Brigham and Women's Hospital.

Public Health Relevance

and Relevance Many patients do not fully understand or remember their discharge instruction when leaving the hospital. The proposed project will develop automated methods to enhance free text discharge instructions with pictographs, in order to improve patient comprehension, recall and adherence.

National Institute of Health (NIH)
National Library of Medicine (NLM)
Research Project (R01)
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Biomedical Library and Informatics Review Committee (BLR)
Program Officer
Sim, Hua-Chuan
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University of Utah
Schools of Medicine
Salt Lake City
United States
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Zeng-Treitler, Qing; Perri, Seneca; Nakamura, Carlos et al. (2014) Evaluation of a pictograph enhancement system for patient instruction: a recall study. J Am Med Inform Assoc 21:1026-31
Nakamura, Carlos; Zeng-Treitler, Qing (2012) A Taxonomy of Representation Strategies in Iconic Communication. Int J Hum Comput Stud 70:535-551
Liao, Katherine P; Cai, Tianxi; Gainer, Vivian et al. (2010) Electronic medical records for discovery research in rheumatoid arthritis. Arthritis Care Res (Hoboken) 62:1120-7
Kim, Hyeoneui; Nakamura, Carlos; Zeng-Treitler, Qing (2009) Assessment of pictographs developed through a participatory design process using an online survey tool. J Med Internet Res 11:e5
Zeng-Treitler, Qing; Kim, Hyeoneui; Hunter, Martha (2008) Improving patient comprehension and recall of discharge instructions by supplementing free texts with pictographs. AMIA Annu Symp Proc :849-53