Patient-Centered Televisit for Chronic Obstructive Pulmonary Disease Discharge Transitions: User-Centered Design Study

Introduction

Chronic obstructive pulmonary disease (COPD) affects over 16 million Americans [1]. A leading cause of hospital readmissions [2] and mortality [3], COPD is projected to cost American health care systems over US $60 billion by 2029 [4]. To reduce costs related to preventable readmissions after an index admission for COPD [5], the Centers for Medicare and Medicaid Services included COPD as part of the Hospital Readmissions Reduction Program (HRRP) financial penalty to reduce hospital readmissions and their associated costs [6,7].

Several factors contribute to readmissions, including inadequate patient self-management of COPD and suboptimal care following a hospital discharge. These factors are often attributed to poor implementation of COPD care guidelines among clinicians during discharge [8], fragmented and inadequate discharge education on strategies to improve skills for COPD self-management at home [9,10], lack of follow-up with patients [11], and insufficient understanding about proper use of medications, including inhaler techniques [12-14]. To address these gaps in medication and symptom self-management, care transition interventions have been explored by many, including our team [15,16]. For instance, pharmacist-led medication reconciliation programs at discharge have been shown to reduce medication discrepancies and 30-day readmission rates for older patients with COPD [17]. Similarly, inhaler technique education using a “Teach-To-Goal” (TTG) approach, consisting of rounds of assessment and education prior to discharge, was shown to reduce all-cause readmissions after initial admissions for COPD compared to simply providing verbal instruction [13,16].

While promising, both medication reconciliation and TTG at discharge can be resource-intensive and challenging to implement at large scale within existing hospital workflows [16,17]. Moreover, although in-hospital pre-discharge interventions may improve patient self-management and potentially reduce readmissions, medication errors still occur in more than half of patients after hospital discharge [18]. Inpatient-only care is likely insufficient for many patients, and researchers recommend that interventions (eg, medication reconciliation and education) extend post-discharge for sustaining medication and COPD self-management skills [19].

To address sustainability and effectiveness concerns, our team helped to develop a pharmacist-led, at-home telehealth program, which has improved inhaler technique and quality of life among patients with COPD, while reducing symptoms [20,21]. Other research has also shown that post-discharge televisit medication reconciliation reduces medication errors across populations [22,23]. The virtual approach for medication review and reconciliation and teaching inhaler technique could enhance COPD education, medication management, and care quality without increasing costs. Informed by published evidence [20,21,24], we developed an end user–informed, comprehensive, post-discharge televisit service termed TELE-TOC (Telehealth Education: Leveraging Electronic Transitions of Care) to facilitate inhaler education and reinforcement of COPD self-management skills and provide opportunities for medication reconciliation and counseling by clinical pharmacists. Here we report on the development and prototyping of the TELE-TOC intervention and identify the components and implementation process necessary to fit TELE-TOC into our current COPD HRRP and DTOC (Discharge Transitions of Care) workflow.

Methods

Study Setting

The study was conducted at the University of Chicago Medicine (UCM). We are developing the TELE-TOC intervention for integration into our existing COPD HRRP [25].

Study Approach

We followed a user-centered design (UCD) approach to ensure TELE-TOC met the needs, preferences, and behaviors of end users (eg, patients, clinicians, and organizational leaders [OLs]) while considering usability and accessibility (eg, older age, limited health, and technology literacy) [26,27]. Multiple end users were actively engaged in the development of TELE-TOC across 3 iterative phases (Figure 1). Phase 1 mapped the current hospital-home-outpatient care transition workflow for patients with COPD, with emphasis on perceived workflow facilitators and barriers from multiple perspectives (ie, patient, caregiver, clinician, and OLs). Data-informed strategies were then developed to address care transition barriers and inform the TELE-TOC role within the current workflow. Phase 2 identified design ideas and implementation considerations using a low-fidelity TELE-TOC prototype with emphasis on potential facilitators and barriers to adoption and implementation. Phase 3 focused on evaluating the usability and feasibility of a high-fidelity TELE-TOC prototype.

‎

Participants

Phases 1 and 2: (1) adult patients admitted for COPD exacerbations enrolled in our COPD HRRP, (2) clinicians (pharmacists, advanced practice nurses [APNs], hospitalists, primary care physicians, pulmonologists, and respiratory therapists), and (3) OLs (patient safety and quality improvement hospital leaders). Phase 1 also included patient caregivers. Phase 3: TELE-TOC end users (adult patients and inpatient clinical pharmacists). While we planned to include caregivers in all phases, they were ultimately only included in Phase 1 due to challenges with further caregiver participation (eg, patient discomfort with caregiver involvement, lack of caregiver availability, passive caregiver, and lack of caregiver altogether).

Data Collection

We used semi-structured interviews to gather participant perspectives on current discharge care transitions. Interview guides were iteratively developed and refined with input from pilot interviews with 2 patients and caregivers from the COPD Foundation, a clinician involved in caring for patients with COPD, and an OL.

Phase 1 mapped current DTOC workflows, ascertained facilitators and barriers, and delineated potential for televisit interventions. Phase 2 assessed attitudes toward the proposed televisit intervention, a low-fidelity prototype of PowerPoint slides with process maps and instructions for inhaler education and identified potential facilitators and barriers to implementation. We asked participants to rate their experiences with medication reconciliation and COPD medication education using a Likert scale from 1 to 5, where 1 indicated “not prepared” or “not good” and 5 indicated “prepared” or “very good.” We requested patient feedback on preferred televisit format (phone, text, or video), comfort levels with video technology, experiences with technical difficulties, and confidence in internet usability. Phase 3 comprised televisit walkthrough usability sessions with 4 patients post-discharge from UCM and 2 clinical pharmacists using the TELE-TOC prototype, as previous research demonstrated that only 3‐5 sessions were required to identify most usability issues [28]. High-fidelity TELE-TOC prototypes consisted of interactive web-based sessions integrated into MyChart (Epic Systems). Additionally, pharmacists piloted a TELE-TOC–specific templated “visit note” in the electronic health record (EHR) to document medication reconciliation and inhaler education (Figure 2). Participants verbalized their actions during the TELE-TOC process. After medication review and inhaler education, patients rated TELE-TOC usability on the system usability scale (SUS) [29] and completed debriefing interviews to assess user satisfaction and suggestions for improvement. Walkthroughs were conducted and recorded via a HIPAA (Health Insurance Portability and Accountability Act)–compliant Zoom platform (Zoom Video Communications Inc) (refer to guides in Multimedia Appendix 1).

‎

Data Coding and Analysis

We followed an inductive (data-driven) thematic analysis approach for Phase 1 [30]. Two researchers (JA and EZ) independently read the data transcripts multiple times and openly coded the data with keywords representing the data, then identified relationships among codes, highlighting areas of similarity and overlap to form subthemes; repeated patterns among established subthemes identified overarching themes. Additionally, interview responses informed the development of a process map for care transitions of patients with COPD.

In Phase 2, we used an inductive-deductive thematic analysis approach to integrate insights on current discharge care transition processes with elements of an evidence-based AHRQ-endorsed care transition framework and implementation science guidelines, informing the design and implementation of our intervention [31]. This framework offers relevant guidelines for addressing challenges in discharge care transition processes and identifies contextual determinants that can inform intervention design and implementation (Figure 3). We used 5 of the 8 AHRQ-endorsed Care Transition Framework domains: intervention characteristics, organizational characteristics, characteristics and roles of clinicians, characteristics and roles of patients, and the process of implementation (Table 1).

‎

First, we (JA and LP) followed an inductive approach consistent with our Phase 1 analysis to generate open codes about the current discharge care transition process and contextual determinants for intervention design and implementation. We then applied the constructs underlying the AHRQ-endorsed Care Transitions Framework (CTF) [32] as a structured coding template to guide deductive thematic analysis. This step helped us to align and integrate our open codes with the constructs within each of the 5 domains in the CTF as outlined in Table 1 [33]. Following this, we then formed overarching themes, or patterns across the data that related to constructs within each care transition domain, highlighting the design and implementation needs for TELE-TOC.

In Phase 3, we (JA and AM) analyzed the cognitive walkthrough transcripts using an inductive thematic analysis approach. Usability, TELE-TOC ease-of-use, and televisit effectiveness were coded and categorized into themes and subthemes (eg, barriers and facilitators). In addition, debriefing interviews were thematically analyzed to identify TELE-TOC user experiences and suggestions for improvement.

Phases 1 and 2 surveys were summarized using basic descriptive statistics (mean). Phase 3 SUS surveys had 10 questions rated from 1 to 5. In accordance with recommendations and standard practice for analysis [29,34], we subtracted 1 from each value for odd-numbered questions sharing positive statements, and we subtracted each value from 5 for even-numbered questions sharing negative statements. After summing the new values across questions, we multiplied this final value by 2.5 and then found the average score across participants.

To ensure validity and reliability, we followed best methodological practices, including member checking and team debriefing [35]. Two researchers independently coded all data, and any inconsistencies were resolved through team discussions to reach a 100% consensus.

Ethical Considerations

This study was approved by the University of Chicago Institutional Review Board (IRB21-0947). All participants were informed of the study purpose, procedures, risks, and rights. Patients and caregivers provided written consent, and clinicians and OLs provided oral consent after reviewing the consent form with study staff. Trained personnel conducted all activities using standardized protocols, with strict confidentiality safeguards to protect participant privacy. Paper records were stored in a locked office, and electronic data were encrypted, password-protected, and housed on secure institutional servers. Hospital data were collected and stored in REDCap (Research Electronic Data Capture; Vanderbilt University), and interview data were maintained on a secure, HIPAA-compliant shared drive. Virtual sessions used the HIPAA-compliant Zoom platform with full security features enabled. Study identification numbers were used in place of personal identifiers for all analytic files. Any identifiable contact information used for scheduling or compensating participants was stored separately from study data and will be destroyed, along with audio recordings, at the conclusion of the study.

Participants in the semi-structured interviews were compensated for their time. Patients and caregivers received a US $50 gift card for each study phase they completed, and clinicians and organizational leaders received a US $15 gift card for each phase in which they participated.

Results

Study Overview

Forty-five participants were enrolled across Phases 1, 2, and 3 (Table 2). Findings are presented across the following themes: Phase 1: current DTOC workflow for patients with COPD enrolled in HRRP; Phases 2 and 3: considerations for TELE-TOC design and implementation.

The mean (SD) patient age across phases ranged from 56.3 (11.0) to 65 (11.3) years (Table 2). Most patients were identified as Black and non-Hispanic, with no representation from White or other racial groups. Sex distribution was evenly split, with 9 female and 9 male patients overall.

Phase 1: Current DTOC Workflow for Patients With COPD

The current inpatient-outpatient discharge transition of care workflow for acute exacerbations of COPD consists of 3 interdependent stages: (1) inpatient pre-discharge (hospital admission to discharge to home), (2) at-home post-discharge (home to outpatient follow-up), and (3) outpatient visit - (Figure 4).

‎

All participants emphasized that each stage relied on the successful execution of activities in the preceding stage, given the interdependence in the workflow. We identified additional key facilitators and barriers to the current DTOC workflow across these stages (Table 3)—with potential impacts on safety and care continuity outcomes (Figure 5).

‎

Inpatient Pre-Discharge Stage

Facilitators

Several facilitators enabled successful inpatient management and preparation for discharge. First, the COPD APN consultation was a mandatory step for enrolling in the COPD HRRP. In addition to clinical recommendations for the primary inpatient team, APNs provided written discharge materials to patients in the form of a COPD Action Plan. When possible, the pharmacy team provided medication reconciliation, which helped clinicians and patients to identify and address issues concerning missing or misused medications. At times, caregivers facilitated this process by playing an active role in medication reconciliation, aiding patients in recalling their home medications (Table 3, Q1 and Q2). Clinicians further noted that the Epic EHR medication dispense report aided in the medication reconciliation process (Table 3, Q3).

At discharge, eligible patients could receive additional medication reconciliation facilitated by the “meds-to-beds” program that delivered prescription medications directly to the bedside before discharge (Table 3, Q4). Finally, the pharmacy team provided inhaler instructions, using the TTG method to assess and encourage patient understanding (Table 3, Q5) [14]. Clinicians and OLs especially emphasized that using TTG at discharge significantly improved patients’ understanding of inhaler usage and follow-up care instructions (Table 3, Q6). Therefore, 67% of patients who responded in Phase 1 (4/6) felt prepared or extremely prepared to manage their COPD following inpatient discharge, with a mean (SD) survey score of 4.5 (1.03). Additionally, 83% of Phase 1 patients (5/6) agreed or strongly agreed that their inhaler education was helpful, with a mean (SD) survey score of 4.5 (0.84).

Clinicians and OLs further noted that an established positive clinician-patient relationship facilitated effective COPD education by creating rapport and improving patient comfort in speaking honestly about their needs (Table 3, Q7).

High patient health literacy also significantly aided the discharge process: both clinicians and patients felt that patients with a clearer understanding of their health were better able to retain and use COPD self-management instructions. They also felt that patients’ health literacy significantly improved medication reporting (Table 3, Q8). Finally, patients benefited from scheduling an outpatient follow-up appointment at discharge, which promoted care continuity and coordination of the next care steps with our program.

Barriers

Several barriers prevented a streamlined workflow and successful COPD education. Only 22% of clinicians in Phase 1 (2/9) felt satisfied with pre-discharge medication reconciliation, rating current practices a mean (SD) of 3 (0.83).

Frustrations were also reported around discharge delays due to inpatient processes that depended on multiple clinicians performing patient care tasks in a timely manner (Table 3, Q9). Another concern was inconsistent insurance coverage for “meds-to-beds.” Clinicians reported other issues with insurance, stating that time-intensive processes (eg, prior authorization and communication with pharmacies) delayed medication delivery (Table 3, Q10). While medication reconciliation was highly recommended at admission and at discharge, limited pharmacy availability during some off-hour admissions resulted in missed consultations. In cases where pharmacists were available, other complications led to a lack of clear or accurate information on patient medication, hindering medication reconciliation (eg, complex medication lists, multiple patient records, undocumented and uninsured pharmacy purchases) (Table 3, Q11). Furthermore, clinicians and OLs observed that patients with poor health literacy struggled to correctly report their home medications, often relying on caregivers to understand their medication lists and provide accurate information (Table 3, Q12). Many clinicians noted that fast-paced education at discharge coupled with poor health literacy often resulted in patients failing to retain instructions (Table 3, Q13).

A few participants noted that educating patients immediately before discharge was not the optimal time, as patients with COPD were disoriented or eager to go home, failing to engage with the discharge COPD education and medication review, and returning home confused about self-management (Table 3, Q14). Furthermore, some patients were unable to contact their inpatient team following discharge when they had questions or were unsure about self-management (Table 3, Q15). Depending on the clinician’s role (eg, respiratory therapist vs nurse vs pharmacist) and experience, the quality of patient education varied widely.

Additionally, with several inpatient team members visiting the patient and multiple lines of COPD therapy, confusion sometimes arose about instructions (Table 3, Q16). A few clinicians reported that with 6‐12 patients to manage simultaneously, challenges such as fatigue and limited understanding of roles and responsibilities in the discharge process prevented complete and successful education (Table 3, Q17 and Q18). Due to excessive clinician workloads, many stated that they frequently prioritized direct care over medication reconciliation and COPD education. As a result, only 17% of Phase 1 clinicians (2/12) felt that patients were prepared to manage their COPD following discharge (Table 3, Q19).

At-Home Post-Discharge Stage

Facilitators

Despite clinician dissatisfaction, 86% of Phase 1 patients (6/7) felt that they were prepared to take their medications following discharge from the hospital, with a mean (SD) score of 4.5 (0.76). Several aspects of the DTOC workflow enabled successful COPD self-management. Patients received a follow-up 48-hour phone call from a COPD registered nurse to check in on health and address any concerns or questions (eg, obtaining medications and post-discharge visit scheduling) (Table 3, Q20). Most patients appreciated the clarification on COPD self-management that the phone call offered (Table 3, Q21). Furthermore, patients enrolled in the MyChart patient portal had easy access to communication with both inpatient and outpatient teams during transitions (Table 3, Q22). Some patients received further support from caregivers who helped with medication compliance and proper inhaler use (Table 3, Q23). Patients with higher health literacy took a proactive role in their COPD self-management and remarked that the discharge materials given to them were useful and effective (Table 3, Q24).

Barriers

Conversely, patients with lower health literacy or patients of lower socioeconomic status are more likely to throw their discharge instructions away or neglect to read them, resulting in improper COPD self-management. In a few cases, patients lost their nebulizers or inhalers (Table 3, Q25 and Q26). Lower socioeconomic status patients also reported competing priorities (eg, housing and food insecurity) that prevented them from focusing on COPD self-management. In addition, some could not afford the cost of their medications and therefore did not fill their prescriptions (Table 3, Q27 and Q28). Finally, clinicians reported poor patient self-management due to individual factors, including substance abuse and mental health issues (Table 3, Q29).

Outpatient Post-Discharge Stage

Facilitators

At outpatient post-discharge follow-up, clinicians continued to monitor patient condition and COPD self-management. Patients were scheduled with COPD APNs for a post-discharge visit within 1‐2 weeks, where ongoing COPD care needs were evaluated and attended to; patients also received additional inhaler training from the pharmacy team. All Phase 2 patients (6/6) felt prepared or extremely prepared to manage their COPD following their outpatient follow-up, with a mean (SD) score of 4.5 (0.55). Like the inpatient setting, successful outpatient follow-ups were supported by an established relationship between the patient and the outpatient team.

Some patients were able to discuss medications more clearly by physically bringing the medications to their appointment or having their caregivers attend. This, along with access to the medication dispense report, helped clinicians to clearly understand the medications and dosages that patients were using (Table 3, Q30 and Q31).

Additional caregiver responsibilities included coordinating transportation to outpatient clinics and providing accurate descriptions of medication and inhaler use (Table 3, Q32).

Barriers

Clinicians reported that many patients missed their follow-up appointments for several reasons. Some could not physically travel to their outpatient follow-ups without assistance (Table 3, Q33). Furthermore, issues with insurance and medication costs continued into the outpatient stage, with patients sacrificing their follow-up appointments to pay for other necessities. Patients also reported going without medications due to expensive copays or if they were uninsured, leading to medication adherence discrepancies (Table 3, Q34).

Even though many patients spoke with their outpatient clinicians, the short appointment duration often resulted in incomplete medication reconciliation and limited assessment of patient literacy about medication use and COPD self-management. These issues, in addition to occasional cultural or language barriers, prevented clear communication and understanding between patient and clinician and sometimes resulted in misunderstandings about at-home care and medication use (Table 3, Q35-Q37).

Phase 2: Potential Role and Impact of Televisit Intervention on DTOC Workflow

Following our assessment of the DTOC workflow, we designed the televisit service with an initial, post-discharge, at-home televisit, followed by additional follow-up televisits before or after outpatient follow-up to maintain continuity of care. We developed a low-fidelity, televisit prototype for virtual pharmacist-led follow-up to provide inhaler training and medication reconciliation. Based on participant feedback, we categorized intervention design requirements as core (fundamental) or flexible (aspects tailored to patient preference) (Figure 6).

‎

Participant-proposed core components included a dedicated care transition clinician role, medication reconciliation, and coordination with outpatient care teams, and COPD education to reinforce inhaler techniques and skills with teach-back. Flexible components, adapted to patient needs and preferences, would include format, structure, reminders, and platform options. Participants felt that multiple options for these components would allow for flexibility and customization based on patients’ preferences and needs. During the televisits, clinicians would use a checklist to ensure thorough inhaler education and teach-back. Additional patient COPD resources would be provided, including an inhaler use handout with visual aids and step-by-step instructions.

Most participants stated that televisits could address several barriers and augment the current DTOC workflow. They specifically mentioned potential improvements in patients’ accessibility to virtual care, which could increase outpatient follow-up adherence. Participants’ insights informed the iterative design of the televisit service, along with details on workflow and components according to patient and clinician preferences. We highlight the potential facilitators and barriers to televisit implementation (informed by the AHRQ-endorsed care transition framework) that may impact its buy-in and adoption (Table 4).

Intervention Characteristics

Facilitators

All participants felt that televisits could be supported with 2‐3 text or phone call reminders to increase attendance and effective usage. While most were flexible with reminder timing, some specifically requested a reminder the day before or on the day of the televisit. Patients who preferred text reminders also felt that helpful messages should include tele-visit details (eg, clinician information, timing, and connection instructions) (Table 4, Q1 and Q2). Several patients believed that clarification for questions and concerns was more easily addressed via televisit between discharge and outpatient follow-up, allowing easy access to a pharmacist in the comfort of their homes (Table 4, Q3 and Q4). All patients and most clinicians and OLs believed that 2‐3 televisits would be optimal (Table 4, Q7). They also felt that patients needed to settle in at home, observe treatment effectiveness, and gather any questions or concerns they have regarding medication use or discharge instructions, so televisits should be scheduled at least a week past discharge (Table 4, Q5 and Q6).

A few clinicians highlighted that using video televisits allowed patients to more easily show pharmacists their medications and inhaler routines (Table 4, Q8 and Q9). Most clinicians and several OLs also felt that the televisit service could be facilitated with the Epic EHR visit note template to document patient information, medication regimen, adverse events, quality of life, and patient counseling. In the event of an emergency, this template could be forwarded to other clinicians. Clinicians stated that documentation could reduce information omission and maintain consistency (Table 4, Q10). Additionally, clinicians suggested that visits should be led by a nurse or pharmacist, as they were knowledgeable about their patients and often had more availability. Some patients also believed that televisits could be more effective with technical support (Table 4, Q11).

Barriers

A few clinicians and OLs highlighted that a fraction of patients might not have internet access, limiting their ability to connect to the televisit. Furthermore, issues with internet connectivity or video quality could prevent clinicians from seeing patients and medications clearly (Table 4, Q12 and Q13).

Clinician Characteristics

Facilitators

To avoid confusion about responsibilities and promote successful televisit implementation, most clinicians felt that a medical assistant, patient service representative, or nurse should schedule televisits. Many also recommended that clear roles and responsibilities be outlined to ensure better coordination and improvement of patient outcomes (eg, medical assistant or patient service representative for scheduling, nurse or pharmacist for televisit) (Table 4, Q14 and Q15).

Barriers

Several clinicians mentioned that time and workload could significantly limit their ability to conduct and document televisits. They worried that extra time after the visit would be required to accurately document the session, increasing the workload and potentially affecting documentation quality (Table 4, Q16). Others also stated that they might struggle with assessing physical symptoms through virtual televisits, impacting patient satisfaction (Table 4, Q17).

Patient Characteristics

Facilitators

Several clinicians felt that patients with high health literacy would be the most proficient users of the televisit service, as they would be more likely to engage during COPD education (Table 4, Q18 and Q19).

Barriers

Some clinicians and OLs worried that poor patient health literacy or technology literacy could negatively impact patient engagement during the visit, limiting the effectiveness of televisit outcomes (Table 4, Q20 and Q21). A total of 50% of Phase 2 patients (3/6) stated they had never used video technology platforms or conducted televisits, and several were not comfortable with FaceTime (Apple, Inc), WhatsApp (WhatsApp LLC), or other video chat technologies, scoring their comfort a mean (SD) score of 2 (2.00). Furthermore, some clinicians predicted that patients might have difficulty using apps such as Zoom videoconferencing software or the MyChart patient portal. Only 1 patient respondent was 100% comfortable using the internet, and many stated that they would need help, with a mean (SD) score of 2.3 (1.63).

Process of Implementation

Facilitators

To successfully implement the televisit, participants all suggested training and education for both clinicians and patients on the visit procedure (Table 4, Q22). A few clinicians and OLs also suggested conducting televisits via phone call if technical issues occurred (Table 4, Q23). Several clinicians believed that using demonstrational videos or other visuals would help to engage patients during televisits, increasing their understanding of COPD management and improving patient outcomes (Table 4, Q24). To encourage buy-in, a few clinicians and patients suggested involving caregivers in the televisit. As caregivers played an active role in patients’ lives, participants speculated that they could encourage treatment adherence and aid the medication reconciliation process (Table 4, Q25).

Barriers

Several clinicians mentioned that some patients might receive care at skilled nursing facilities, which could introduce patient management conflict between tele-visit clinicians and in-facility clinicians (Table 4, Q26).

Organizational Characteristics

Facilitators

Our participants did not report any organizational facilitators within our data.

Barriers

All clinicians and some OLs strongly felt that secured funding for and clear, defined ownership of the televisit service were essential for long-term sustainability and consistent clinician accountability (Table 4, Q27). A small number of clinicians also highlighted their lack of dedicated space to conduct televisits, potentially making both the clinician and patient uncomfortable and affecting the quality of communication (Table 4, Q28).

Phase 3: Participant Perceptions of TELE-TOC Prototype

Following 5 walkthroughs with our high-fidelity TELE-TOC prototype, patients and pharmacists discussed their perceptions of TELE-TOC and identified facilitators and barriers to TELE-TOC overall, medication reconciliation, and inhaler education. Furthermore, suggestions for improvement were made (Table 5).

Participant Perceptions of TELE-TOC

Patients and pharmacists described an overall positive experience with TELE-TOC. Patient SUS scores were reported as an average of 97.5/100, indicating that patients found TELE-TOC to be user-friendly and easy to use. Furthermore, when asked to rate the overall quality of TELE-TOC on a Likert scale from 1 (very poor) to 5 (very good), on average, patients rated TELE-TOC 5/5, while pharmacists rated TELE-TOC 3.8/5.

Most participants felt that TELE-TOC was not difficult to engage with and even suggested lengthening the sessions to create more time for questions and patient-specific concerns (Table 5, Q1 and Q2). When asked about TELE-TOC content, patients responded that they did not feel that any content needed to be removed; on the contrary, they requested the addition of more in-depth COPD information. Pharmacists and patients agreed that TELE-TOC was engaging and helpful, especially the inhaler education, which patients described as more hands-on than their discharge education and in-person follow-up visits (Table 5, Q3 and Q4). Patients stressed that TELE-TOC’s follow-up helped them to feel cared for and improved their confidence in medication management and inhaler use (Table 5, Q5 and Q6). They also felt that TELE-TOC motivated them to learn more and improve their COPD management.

Experiences With Medication Reconciliation Component of TELE-TOC

Facilitators

Regarding medication reconciliation, a pharmacist noted that it was easier to confirm which medications each patient was taking based on what they presented on video (Table 5, Q7). Furthermore, use of MyChart allowed pharmacists to easily access medication lists to double-check medication names, dosages, and frequency of use (Table 5, Q8 and Q9). Through TELE-TOC, pharmacists could identify prescription discrepancies while helping patients to better understand the purpose of each medication (Table 5, Q10 and Q11).

Barriers

Challenges with medication reconciliation included lack of patient preparation and low patient health literacy. Pharmacists noted that patients were not always adequately prepared to review their medication lists and may need reminders to have their medications ready for review in future sessions (Table 5, Q12). Some patients also simply read their medication labels but were unable to fully understand their medication management, even with help from the pharmacists.

Experiences With Inhaler Education Component of TELE-TOC

Facilitators

During inhaler education, video technology enabled pharmacists to see how patients used their inhalers and instruct them accordingly (Table 5, Q13). Most patients agreed that video technology made instructions easier to follow through visual feedback. They also enjoyed the teach-back method used by pharmacists, noting that it felt more engaging and helped them process and understand clinician instructions (Table 5, Q14).

Barriers

While most patients felt satisfied with their inhaler education from the TELE-TOC pharmacist, others reported that the lack of further in-depth education left them with an incomplete understanding of how to use an inhaler (Table 5, Q15). They felt that even with the education provided during the session, they were still not fully confident in their inhaler use.

TELE-TOC Use and Implementation

Facilitators

Overall, patients noted that TELE-TOC’s flow was easy to follow and led to a more streamlined process of medication reconciliation and inhaler education (Table 5, Q16). Both pharmacist interventionists agreed that both components of TELE-TOC were easy to complete smoothly, and TELE-TOC did not require too much extra work to conduct (Table 5, Q17). Using video technology also allowed patients to speak to their pharmacists from the comfort of their home. Unanimously, patients agreed that the telemedicine nature of the intervention allowed for improved access to their clinicians and increased the likelihood of attending the virtual session, in comparison to a similar in-person follow-up (Table 5, Q18-Q20). Additional facilitators to TELE-TOC implementation included patient reminders via MyChart to ensure patient attendance (Table 5, Q21), as well as technology literacy among pharmacists to correctly set up visits. Both pharmacists noted that they did not have issues with navigating TELE-TOC or MyChart.

Barriers

Patients and pharmacists listed different barriers to TELE-TOC implementation. Several patients believed that TELE-TOC was helpful for those who were unfamiliar with their medications or inhalers, but others voiced the desire to learn more about their COPD and management beyond the general information provided alongside medication and inhaler education. For example, some patients wanted to better understand COPD epidemiology, along with signs and symptoms to watch out for at home; lack of further in-depth discussion about their condition and experiences left them feeling mildly dissatisfied (Table 5, Q22).

Technology literacy and technical issues were observed as impediments to conducting TELE-TOC. Over multiple sessions, technical issues within Epic EHR and over Zoom made TELE-TOC difficult to conduct (Table 5, Q23 and Q24). Further, while patients stated that they did not have too much difficulty or concern with navigating the technology required to conduct TELE-TOC, issues such as forgotten passwords, confusion about MyChart login information, and misunderstandings about Zoom settings were observed during walkthroughs. One patient even noted that without technology assistance from the clinician or a caregiver, they would likely have given up on TELE-TOC (Table 5, Q25). These issues were quickly resolved with the help of TELE-TOC pharmacists, who were trained to provide several solutions to technical barriers (eg, switching to telephone calls, moving from MyChart to Doximity, and providing clear instructions in the event of patient problems with log-in or calling).

Both pharmacists also provided feedback on the TELE-TOC workflow and tools, primarily voicing initial dissatisfaction with the “visit note.” They initially felt that the “visit note” was not structured in a way that allowed for streamlined conversation and were unsure of the needed depth for the notes (Table 5, Q26). As both pharmacists conducted more walkthroughs, they verbalized that the structure and clarity of the “visit note” greatly improved over time.

Suggestions for Improving TELE-TOC Content, Function, and Implementation

Following the discussion of the barriers to their TELE-TOC experiences, participants provided a few suggestions to mitigate these challenges. To combat a lack of patient preparation for and to streamline medication reconciliation, it was suggested that pharmacists ask patients to preemptively prepare their medications prior to TELE-TOC (Table 5, Q27). Furthermore, more detailed education and anticipatory instructions on inhaler use and general COPD management were suggested as a method to support patients who still felt unsure in how to care for their conditions (Table 5, Q28 and Q29).

Participants also felt that providing clear instructions and a tutorial on how to use Zoom and MyChart technology would be helpful in assisting patients with lower technology literacy (Table 5, Q30). Furthermore, amendments to the “visit note” were suggested: sequence the note in alignment with the structure of each session and provide clearer instructions for pharmacists to complete the document (Table 5, Q31). Other suggestions included establishing an additional group format of TELE-TOC to provide inhaler and COPD education for multiple patients at once (Table 5, Q28), as well as using TELE-TOC as an additional source of support for patients with medication needs, such as checking on refills or checking for duplicate therapies (Table 5, Q32).

Discussion

Principal Results

Our 3-phase, UCD approach tailored and optimized an evidence-based televisit medication management and education intervention for patients with COPD transitioning from hospital to home. We identified facilitators, barriers, and interdependencies across the current DTOC workflow for patients with COPD, seeking to amend the workflow and improve patient outcomes. Key facilitators across settings included the “meds-to-beds” program and caregiver support, while challenges to effective care included inopportune education timing, inaccurate medication records, and limited outpatient follow-ups. These findings suggested the need for more comprehensive post-discharge patient support, which indicates the utility of the TELE-TOC intervention.

While the study was open to patients of all races and ethnicities, all enrolled patients identified as Black and non-Hispanic. This aligns with trends observed in UCM’s COPD HRRP, in which a large proportion of eligible patients are Black. As a result, our study sample reflects the demographic makeup of UCM’s patient population. Several factors, including lower utility of health care services, health insurance coverage, and behavioral differences (eg, smoking habits), have increased COPD’s impact on Black patients [36,37]. Hence, Black patients hospitalized with COPD exhibit greater symptom severity and have significantly higher odds of 30-day readmission in comparison to non-Hispanic White patients [38-40]. Despite this disproportionate effect, very few studies examining the implementation and effectiveness of COPD DTOC interventions have explicitly included Black populations [41].

Comparisons With Prior Work

Our study corroborates existing literature, which emphasizes clinician COPD training and positive patient-clinician relationships as key facilitators to successful post-discharge care, alongside key barriers such as resource constraints, limited patient understanding of the education provided, and inappropriate allocation of tasks among clinical staff [17,42,43]. However, we identified additional barriers not widely discussed in prior research, such as patients using cash online pharmacies, resulting in undocumented medication use. This underscores the importance of accurate medication reconciliation, which is often limited in hospital settings.

We then explored how to address these barriers using pharmacy-led, virtual, in-home televisits for medication reconciliation and inhaler education. Our data suggested that televisits would be well-received and engaging due to their convenience and the addition of a dedicated pharmacist during the critical care transition period. Prior literature also highlighted the significant advantages of telehealth in medication management and virtual health education. For example, a previous study found that patients benefited more from telehealth (vs usual care) medication reconciliation, showed higher engagement and buy-in, and maintained better adherence to prescribed medications [44]. Further, multiple reviews [24,45,46] noted that telehealth-based interventions have improved patients’ post-discharge healthcare outcomes and quality of life.

Based on these insights, we refined the TELE-TOC components and workflow. Notably, TELE-TOC offers a customizable telehealth experience that tailors televisit format (eg, visit mode, dose, frequency, and structure) to meet patient preferences and clinical needs, enhancing engagement and ensuring more personalized care while retaining core patient discharge components. Both patients and clinicians found TELE-TOC effective and efficient for medication reconciliation and comprehensive inhaler education. Despite some patients suspecting they would struggle to log in and navigate to TELE-TOC on their own, SUS scores remained high due to support and clear instructions from clinicians. Furthermore, due to a 766% increase in telemedicine encounters following the COVID-19 pandemic [47,48], many patients and providers report improvements in their televisit competency, which could explain the high success rate of TELE-TOC among our participants. Apart from a few technical difficulties, both patients and providers noted positive experiences with TELE-TOC usability and effectiveness [49]; other studies have reported similar feasibility and usability of eHealth interventions for patients with chronic conditions [50]. Other key success factors included remote monitoring and feedback from clinicians, visual aids via videoconferencing tools, and access to medication lists at home. Use of previously successful implementation strategies, such as patient-personalized televisit format, inhaler education teach-back, and TTG methods, was crucial to the success of our TELE-TOC prototype [13,16,51]. Several implementation barriers were addressed, including clinician availability for COPD education and patient forgetfulness about medications [52-58]. However, structural barriers, such as patient financial burden related to payment structures, remain unaddressed [52,59-61].

To evaluate the clinical impact of TELE-TOC, we are currently conducting a randomized controlled trial evaluating the effectiveness and implementation potential of TELE-TOC compared to usual care at UCM (NCT06461403), which is expected to be completed in 2026 [62]. Our primary effectiveness outcome assesses inhaler technique at 30 days after discharge, based on a validated 12-step checklist. Secondary outcomes include acute care revisits, rehospitalizations, and mortality rates at 30, 90, and 180 days post-discharge, in addition to medication errors, changes in COPD symptoms based on the COPD Assessment Test and the Modified Medical Research Council dyspnea scale, and inhaler technique. Our primary implementation outcome is intervention reach. If successful, TELE-TOC could serve as a scalable model for improving COPD discharge care transitions and reducing avoidable acute exacerbations of COPD readmissions.

Limitations

We acknowledge our study limitations. First, this is a single-site study at an urban academic medical center, which may limit generalizability. In particular, the racial homogeneity of our study sample may limit the generalizability of our findings to the broader US population. Nevertheless, this study attempts to address the research gap in developing COPD discharge care transition interventions to meet the needs of Black patients. Second, we acknowledge that within our small sample for Phase 3, some patients mentioned familiarity and experience with using phones and computers to perform tasks, including video calls. This experience with technology may strongly contribute to their usability ratings, and we acknowledge that our SUS findings may reflect limited sample diversity. However, as previously mentioned, televisit proficiency increased significantly during the COVID-19 pandemic, and we anticipate that within our current randomized controlled trial, with a larger, more diverse sample, we may see similar TELE-TOC proficiency among our target population. Third, the feasibility of televisit interventions may not be applicable across health care organizations, depending on institutional resources. To best address this, we will develop an evidence-based roadmap for pragmatic implementation and dissemination of TELE-TOC across diverse rural, urban, and suburban US hospitals.

Conclusions

We adopted a UCD approach to codevelop and optimize a pragmatic and patient-centered COPD televisit intervention to support hospital-to-home care transitions. The goals of the proposed TELE-TOC intervention were to reduce unnecessary readmissions and improve continuity of care, provide impactful medication management and education to improve outcomes such as COPD symptom control, and ascertain implementation outcomes, including reach, sustainability, and scalability of TELE-TOC.