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Bridging Gaps in Care

March 8, 2012
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Quality improvement experts and IT vendors as a care transition team

One of the most persistent problems in healthcare is care transitions between sites of care. Unfortunately, patients who find themselves caught in that gap don’t have a lot of support. That’s the view of Pat Rutherford, R.N., vice president of the Institute for Healthcare Improvements in Cambridge, Mass.

In a recent interview, Rutherford said the healthcare industry has done a good job of raising the awareness of the need for better care transitions, but there is still a long way to go in making major breakthroughs. She sees a need for better partnerships between IT vendors and quality improvement experts, who, she says, “are good at process improvements.”

IT vendors, in her view, have a major challenge when it comes to care transitions, because they are trying to implement architecture and infrastructure of system-wide processes in a fragmented healthcare system. “You have cross-vendor and cross-regional problems and interfaces between different platforms,” she said. “There are myriad problems that vendors are facing because healthcare is fragmented.”

Rutherford doesn’t think there is any low hanging fruit when it comes to solving the problems in care transitions, but she thinks that quality experts and IT vendors can co-design products that better bridge the gaps in care transitions.

She says quality improvement experts, who are good at process improvements, have a lot to offer IT vendors. They can help co-design products that can bridge the care transition gap by paying close attention to the users, whether they are patients or caregivers, and adapting their feedback into their product development. “What problems does the patient have using it? What problems do the primary care provider and the office practice have using it? Does it fit into their workflow?” she asks.

Over the long haul, it’s a partnership that can lead to a more cohesive plan of care that would allow sites of care to work together, she said.



Great post. This is one of the most important goals of Meaningful Use, Stage 2 and beyond. I have received patient safety training from the IHI, supported several clients in IHI collaboratives, and witnessed the disconnect between developers/implementers (both vendors and home-grown shops) and the healthcare improvement community.

I am particularly proud of this recent post, , calling attention to Novaces and Vickie Kamataris' leadership. They point out that clarifying the problems and improvement opportunities requires talented, skillful and experienced observation, long before HCIT enablement can and should be considered. And, as the IHI would agree, it often requires using the right tool.

Part of the historical challenge of using HCIT well follows from getting these clinical requirements clear and specific.

Where do I see the partnerships coming to advance the state of the art in care transitions:

- Clinical Information Modelling Initiative (

- HIMSS EHR Association (

- And, most importantly, the sharing of lessons in the Healthcare Informatics articles (eg and blogs. My most recent blog, , talks explicitly about the critical role of coaching, built on the story of a real, community hospital CMIO's work to improve care transitions in Congestive Heart Failure. That's the highest volume discharge-to-home. His work, challenges and accomplishments highlight what it takes to execute effective partnerships. It is an "over the long haul" affair, as Pat Rutherford calls out in closing.


Thanks for your excellent reply, your comments regarding medication reconciliation, and links to groups that are working on this issue. As Pat Rutherford of IHI has noted, there are no simple solutions, but it is encouraging to know that there is progress being made on this long-term challenge.