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How HIT Can Make Care Transitions Safer

Gienna Shaw, for HealthLeaders Media, October 17, 2011

In a crowd-sourcing exercise, most participants (58%) agreed that care plans fail to include medical and social factors, fail to coordinate interdisciplinary input (including patient input), do not include processes and milestones, and are not reconciled across time and setting.


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 More than 50% said essential care providers often have no input into the transition plan, including the primary care physician, the public health department, family, home health agencies, and pharmaceutical companies.

Among the most promising existing IT solutions, according to the group:

  • Interoperable information exchange, including clinician and pharmacy data.
  • Consistent implementation of a proven model of communication among patients and providers.
  • More effective risk stratification that incorporates both clinical and social factors.
  • And the group said future innovations should focus on:
  •  Feedback loops to identify when patients do not follow discharge instructions--by filling prescriptions or making follow-up appointments, for example.
  • Electronic medical records and personal health records that merge medication information, including data from local pharmacies that provide medication therapy management.

Lasting and significant change will require large-scale, systemic change, said George Bo-Linn, MD, chief program officer of the San Francisco Bay Area Program with the Gordon and Betty Moore Foundation. "By expanding the smart use of health information technology during transitions, we are paving the way for smarter, lower-cost health care and new levels of sustainable healthcare quality."

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