How HIT Can Make Care Transitions Safer

So much can go wrong during so-called transitions of care. Lack of communication and coordination with primary care physicians when a patient is discharged from the hospital, for example, can compromise patient safety, lead to ED visits and readmissions, and cause a host of other problems.

So how can health information technology make care transitions safer and more seamless?

That was the question posed at a working meeting of developers, healthcare providers, patient organizations, technology companies, health IT experts, and officials from government agencies in Washington, DC, on Friday. Kaiser Permanente sponsored the event along with the John A. Hartford Foundation and the Gordon and Betty Moore Foundation. Participants worked to identify immediate and short-term technology solutions to improve care transitions and brainstormed new ideas.

"It is increasingly clear that health information technology, implemented in a patient-centered way, has vast potential to help us reduce the number of injuries, accidents, and re-hospitalizations that are causing stress and harm to patients, particularly older patients, every year," Christopher Langston, PhD, program director of the John A. Hartford Foundation, said in a statement.

Participants cited poor communication and coordination among providers and lack of patient input as the most pressing problems. Among the most promising solutions are more effective risk stratification as well as better use of home monitoring, mobile health, and telehealth and IT systems to allow primary care providers to track their patients along the continuum of care and to facilitate a feedback loop among patients, providers, pharmacists, and others.

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.

 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."

Bo-Linn was one of several leaders at the event who challenged participants to think big. "We're not radical enough," he said during a panel discussion toward the end of the day. "These are great ideas but that's so last Thursday already ... I don't want a plan, I want action."

Many of the solutions to make care transitions safer already exist, he said--and yet even simple solutions aren't implemented. An elderly woman is discharged and her daughter lives nearby but works during the day? Set them up with Skype, he said. Her house has too many stairs, putting her at risk for a fall? Install a motion detector.

How do you help ensure the health of an 11-year-old asthma patient who is discharged to a household of smokers? Install air quality monitors and give financial incentives to the adults to maintain good air quality. "In fact, you can make it an automatic payment," he said.

And you can monitor how often and when she uses her inhaler; send text medication reminders to her school nurse.

There is a need to identify the "basic stuff that's not happening today, that's killing people because it's not happening," Farzad Mostashari, MD, national coordinator for health IT, told participants. That could be something as simple as ordering discharge wheelchairs in more timely and efficient manners or creating systems to notify a primary care physician when his or her patient is treated in the ED or admitted to the hospital, he said.