The goal of my investigation is to improve the quality and safety of care provided to general medical patients. I do this as a clinical researcher, spending the majority of my time engaged in grant-funded quality improvement research studies; as an administrator, overseeing quality improvement activities for the Hospitalist Service, for BWH, and for Partners Healthcare; and as an educator, teaching residents and students during my time as a hospitalist on the BWH General Medicine Service and mentoring residents, fellows, and junior faculty.
As an investigator, my goal is to design, implement, and rigorously evaluate quality improvement and patient safety interventions. Content areas of my work include safe and effective medication use; communication among health care providers and between patients, caregivers, and providers; and transitions in care between different health care settings. For example, in the area of medication reconciliation, an early study of mine demonstrated the benefit of novel health information technology (HIT) and process redesign to reduce unintentional medication discrepancies (Arch Intern Med; 2009). This work led to the Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS), a five-hospital “real-world” study using mentored implementation and a toolkit of best practices that demonstrated a reduction in medication discrepancies over baseline temporal trends. I am currently leading MARQUIS2, which is at 18 sites, using a refined version of our toolkit and lessons learned from the first MARQUIS study; results to date demonstrate a 35% reduction in medication discrepancies in patients who received interventions. The Leapfrog Group has adopted our measure of medication reconciliation such that hundreds of hospitals are now measuring medication discrepancies using our methodology. An upcoming study will focus on post-discharge pharmacist-led interventions to improve medication safety after discharge, powered to demonstrate reductions in readmissions in order to promote widespread adoption.
In the area of care transitions, early studies focused on predictors of hospital readmission, including easy-to-calculate scoring systems (JGIM; 2010). Later work in this area included a “HOSPITAL” score that has been validated in 9 hospitals in 4 countries (JAMA Intern Med; 2016). More recently, I led a two-hospital study funded by PCORI of a multi-faceted intervention to improve transitions of care within the Partners Accountable Care Organization. The intervention reduced post-discharge adverse events but not readmissions; a mixed-methods analysis revealed a variety of reasons for this finding, which has local and national implications for how best to organize and finance health care such that it supports successful care transitions.
Studies of HIT have included several novel and successful interventions, including a patient portal linked to our electronic health record (EHR) that improved medication safety (JAMIA; 2012); a tool to communicate the findings of test results that are pending at hospital discharge (JAMIA; 2014); and a patient-safety dashboard that identifies risks in real-time and alerts providers of actions that may need to be taken (J Comm J Qual Pat Saf; 2017). In the case of the patient-safety dashboard, our tool directly links to a commercial EHR and has the potential to be adopted at hundreds of hospitals. A recently submitted grant proposal aims to develop inpatient tools to identify possible diagnostic errors in real-time using the EHR.
Other reflections of my impact on the field include over a hundred peer-reviewed publications in high-impact journals such as Archives of Internal Medicine/JAMA Internal Medicine, Journal of Hospital Medicine, and Journal of the American Medical Informatics Association; local and national position papers on resident handoffs and hospital discharge; numerous invited talks at academic medical centers (e.g., visiting professor, grand rounds) and at national meetings of the Society of Hospital Medicine, Society of General Internal Medicine, and the American College of Physicians, including plenary sessions and workshops on medication safety. I have been continuously funded since coming to BWH in 2001, with funding sources including AHRQ, NIH (NHLBI, NIDA), and PCORI; Foundations such as the Moore Foundation and ASHP; local funding from BWH, Partners, and CRICO; and investigator-initiated studies funded by industry.
I have also served on and led a number of committees at BWH and Partners Healthcare to improve transitions of care, handoffs, medication safety, and HIT. I co-chaired the Partners Patient Safety Transitions in Care committee for 8 years, during which time we improved the quality of discharge documentation across all seven Partners hospitals, and in so doing created standardized metrics of quality that became pay-for-performance measures and were adapted by Massachusetts in its state-wide efforts to improve quality. I have also led BWH and Partners-wide efforts to improve medication reconciliation, both before and after Partners implemented Epic as our EHR.
As an educator, I have focused my attention on training medical housestaff in medication safety and transitions in care and to share my interests and expertise in content areas such as inpatient diabetes management and evaluation of patients with syncope. As Director of Clinical Research for the BWH Hospitalist Service, my goals are to support the research efforts of my colleagues. I take particular satisfaction in the relationships I have formed with residents, fellows, and colleagues as their research advisors and mentors, many of whom are now on their way to successful careers in academic medicine, hospital administration, and research. Finally, starting this summer, we enrolled the first class of fellows in our Harvard-BWH Hospital Medicine Research Fellowship, which I now direct.