Creating Care Transitions That Reduce Readmissions and Improve the Health of Communities

There’s been this sentiment expressed by providers that, ‘Oh, we’ve got to get our e-mail systems set up a certain way.’ But honestly, if you can just get this connection to work, that helps. And everybody believes that the best transition occurs when the hospitalist has a conversation with the primary care physician at the point of discharge, but that never works out in terms of the primary care physician’s workflow. So if you can just post that notice to the primary care physicians, that would be great. I’ve long said, what we need essentially is a HIPAA-compliant bulletin board for this communication.

Perhaps through the federal DIRECT program?

Yes, perhaps; and maybe the primary care physician only needs to know one specific piece of new information, so maybe it’s just that Betsy Smith had one change in meds; that can make all the difference.

What could CIOs, CMIOs, and other healthcare IT leaders be doing right now to lay these needed foundations?

I would urge them to think about creating some version of this electronic bulletin board; it seems to me that there ought to be a way to facilitate that. And if there were a great way to securely post messages, then the information could be texted, and then the doctor could go and check, in their own time, on Betsy Smith [the patient]. And then if they see that, ohmygosh, Betsy Smith is a train wreck, his office could reach out to Betsy Smith and get her in for an appointment right away. But at least that would allow the person receiving the medical responsibility to be in charge of deciding the level of worry that is appropriate.