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“If we want to ensure safe, seamless care transitions for patients recovering from hospitalization, we need to use our IT systems and digital tools more effectively to support patients and clinicians. AHRQ funding has enabled me to design, develop, implement, and test digital health interventions that improve patient safety across care settings.”

Care transition or moving from one healthcare setting to another, such as from the hospital to home, is a vulnerable time for patients. Between 19 to 28 percent of patients experience adverse events during care transitions. Potential problems include medication errors, falls, infections, procedural complications, management errors, diagnostic errors, lack of adequate monitoring, and lack of timely follow-up care. These adverse events, which may lead to hospital readmissions, represent an ongoing threat to patient safety.

Anuj Dalal, M.D., associate physician at Brigham and Women's Hospital and associate professor of medicine at Harvard Medical School in Boston, Massachusetts, is helping to reduce adverse events during care transitions by designing, developing, and implementing digital health tools that promote patient engagement, facilitate effective patient-clinician communication, and automate workflow tasks by leveraging the electronic health record (EHR) and patient-generated health data. These tools can improve patient safety and outcomes by empowering patients to know more precisely when to interact with care teams and provide tools to do so more easily. They also can notify clinicians of important pending tasks, such as test results, and predict potential post-discharge adverse events.

Dr. Dalal was awarded his first AHRQ in 2009 to develop an automatic notification system to alert physicians of final test results after a patient is discharged. “Physicians often are unaware of test results that return after a patient leaves the hospital—a problem which could lead to delays in diagnosis, missed treatment opportunities, unnecessary ordering of additional tests, and patient harm,” said Dr. Dalal. During the 3-year project, his team surveyed attending physicians and primary care providers to study whether the notification system improved physicians' awareness of test results. His research found that the system did and on these results. According to Dr. Dalal, hospital executives are now using the findings to inform how test results are managed as part of their health information systems.

Building on his efforts to reduce adverse events during care transitions, Dr. Dalal received another 3-year AHRQ in 2016 to develop and an interactive toolkit that helps patients prepare for hospital discharge. The promotes self-management by patients and caregivers during transitions. Dr. Dalal noted that the tool helps promote more timely conversations between patients and the clinical team so that concerns are addressed before discharge.

With a continued focus on improving patient safety, Dr. Dalal served as a co-principal investigator on a 4-year AHRQ-funded Patient Safety Learning Laboratory in 2018. The project, “Improving the Safety of Diagnosis and Therapy in the Inpatient Setting,” included a team from diverse disciplines—including clinicians, human factors experts, and systems engineers—who an approach for investigating diagnostic errors by for hospital patients, and to improve diagnostic safety in acute care. According to Dr. Dalal, the researchers are using what they learned to improve overall diagnostic safety at their institution and as part of , also funded by AHRQ.

In 2021, Dr. Dalal received a 5-year AHRQ to create a digital health app that predicts the risk of post-discharge adverse events and engages patients with multiple chronic conditions to monitor their symptoms and general health more closely. He noted that “clinically-integrated digital health apps have the potential to more accurately predict risk of adverse events that may happen after discharge and improve communication for patients, their caregivers, and the care team when the need for escalation is clear.” Through this project, Dr. Dalal aims to create a predictive model that identifies medical issues that a person may experience after discharge by collecting relevant patient-reported outcomes and combining these with electronic health record data. The app will enable patients to self-assess their discharge readiness using the discharge preparation checklist prior to leaving. After their discharge, it will enable patients to monitor new and worsening symptoms, self-assess their general health using patient-reported outcomes questionnaires, and receive individualized self-management advice. It also will help patients to understand their individualized risks of adverse events during care transitions. The project will end August 31, 2026.

In related work, Dr. Dalal received a 3-year in 2023 to design, develop, implement, and evaluate methods for allowing older hospitalized patients living with multiple chronic conditions to locate and share their electronic health records for patient safety research. These methods will enable the patient’s current facility to gain an understanding of the treatments and tests a patient has undergone at other facilities, enabling continuous and quality care and reducing the potential for adverse events during hospitalizations. The project will end May 31, 2026.

Dr. Dalal is a member of the American Medical Informatics Association and the Society of Hospital Medicine.

Principal Investigator: Anuj Dalal, M.D.
Institution: Harvard University
Grantee Since: 2009
Type of Grant: Various

Related AHRQ Resources

• Hospital Discharge
• Patient Safety
• Taking Care of Myself: A Guide for When I Leave the Hospital
• Transitions of Care

Return to AHRQ Grantee Profiles