We have conducted a pilot study to develop pictographs for discharge instructions. Receiving proper discharge instruction has significant impact on patient outcome and satisfaction. One recent study analyzed the effect of JCAHO-required discharge instruction on heart failure patients. It found that patients who received all required instructions were significantly less likely to be readmitted for any cause and for heart failure than those who did not [14
]. A large survey study also found that patients’ ratings of “instructions given about how to care for yourself at home” showed a strong, consistent positive relationship with overall patient satisfaction [7
Clearly, discharge instructions should not only be given, but also be made comprehensible to patients and families. Unfortunately, patients often have difficulty understanding and remembering medical instructions. In a study of Emergency department (ED) discharge instructions, more than half of the patients did not fully comprehend the free text instructions they received [10
]. According to another study, patients, on average, forget half of what they were told by a doctor within 5 minutes of leaving the outpatient consultation room [15
In this pilot study, we developed a small set of pictographs through a participatory design process to supplement the free text discharge instructions. These pictographs were then used to enhance two mock-up discharge instructions. Tested on 13 healthy volunteers, the immediate and delayed recall rates were both higher for the pictograph enhanced instructions than the text only instructions. This suggests that pictographs could play an important role in improving the comprehension and recall of free text discharge instructions.
One lesson we learned from this study is the importance of involving both clinicians and lay people in the pictograph design process. The extensive bed-side and patient education experience of the two clinicians (nurses) who participated in the study were especially important in identifying instructions that could be improved with illustration and creating the initial designs. The two lay people who participated in the study contributed significantly to the critique of the initial designs, but made few suggestions as to what instructions should be illustrated and what the initial designs should look like. On one hand, maybe they did not make many suggestions because they were able to understand the instructions themselves and they did not have much experience explaining clinical instructions to others. On the other hand, if they did not understand the instructions themselves, they would not be able to help with creating the initial illustrations.
Recall is often used as a proxy for comprehension in research studies. Nevertheless, perfect comprehension does not always result in perfect recall. Even when a reader can understand the text, seeing a picture could help with recall. Some instructions (e.g. “Avoid tub bath until the wound is completely healed.”) should be comprehensible to most if not all of the subjects in our study. Nevertheless, seeing the picture in , appeared to help some subjects remember the “avoid tub bath” instruction.
Pictograph representation of the “Avoid tub bath” instruction.
For patients who have low health literacy or general English literacy, the benefit of pictographs could be even bigger. The sample size in our evaluation is too small and the sample is not diverse enough to test if the pictograph enhanced instructions would benefit a low literacy audience more. Past research, however, has indicated that graphical illustrations especially improve recall of conceptual knowledge and problem solving information of individuals who have little expertise in the subject matter [11
In the study, the subjects’ unfamiliarity with and lack of personal interest in the specific medical condition might have lowered their recall rate. Delayed recall for real patients is probably higher if they try to comply with the instructions during the following days. A repeated measure with real patients might even induce higher recall rates the second time. On the other hand, unlike real patients, the healthy subjects were not suffering from any physical and emotional distress that would hinder the comprehension and recall of information. In the evaluation, the order of the versions (text and pictograph) was not randomized, which may cause carry-over effects. Because of the small sample size, we also did not analyze which pictographs or pictographs of which domains were particularly helpful.
In the future, we hope to develop a large set of pictographs and test them on actual discharge instructions of real patients. More importantly, we plan to develop a software tool that will be able to parse patient-specific instructions and enhance them with appropriate pictographs.