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Care Transitions Workgroup Explores IT

October 20, 2011
by John DeGaspari
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Issues and practices around health IT to improve patient care after a hospital stay

On Oct. 14, a group of about 200 policy and health IT experts, providers, patient organizations, technology companies and government agencies met in Washington, D.C., to address poor transitions in care, which cause of millions of preventable readmissions, unnecessarily driving up healthcare costs. The meeting was sponsored by Kaiser Permanente, the Office of the National Coordinator for Health IT and Partnership for Patients, The John A. Hartford Foundation, and The Gordon and Betty Moore Foundation. Speakers included Farzad Mostashari, M.D., national coordinator for health IT, and Todd Park, chief technology officer of the Department of Health and Humans Services.

“Care transitions are difficult for patients and families for many reasons,” said Park ahead of the meeting. “If we can clearly identify the most challenging issues, we can help accelerate the work by providers, innovators and investors across the country who are energized to help improve care for patients.”

During the meeting, Dr. Mostashari urged participants to embrace technology as a way of improving care transitions. “The business case is increasingly there, in that we are seeing how care is paid for in private medical plans, in Medicaid and Medicare,” he said. While he acknowledged that the fee-for-service model still predominates, new payment models are coming. “The question is, when new models of payment come, are we going to deliver more coordinated, safer, higher quality, lower cost care?” he asked.

Farzad Mostashari, M.D.

Attendees addressed challenges and opportunities in five working groups focusing on four areas: the discharge process; medication reconciliation, information flow and feedback; and patient and caregiver activation. Each group addressed the most important problems from the patients’ and caregivers’ perspectives; where IT is effectively addressing those issues now; and where innovation is most needed.

Here are brief summaries of what each breakout group found.

Discharge process: There is the need for an integrated plan that includes the patient’s point of view and challenges of caregivers in delivering care. There is a concern that patients are not getting an integrated view of the care plan, which lacks their input. Although there are plenty of software solutions, they exist in small pockets. The challenge is to implement scale the solutions across all of the providers. There is also a need for better measurement of how well solutions work best.

In addition, the group noted that the first 72 hours after discharge were when patients are often in a confused state. Risk stratification can mitigate the risk of readmission, but it is not widely done. Medication reconciliation was also identified as a key problem that needs to be addressed. There is a need for technology that can identify to recognize and stratify risk, using information that is available at the hospital; simple consumer technology such as barcodes would help caregivers do a better job reconciling medications, the group said.

Medication administration: Two problems were identified, one around the drug selection process and the other around the patient, with regard to adherence issues. Technologies exist to pull down medication histories of patients from the electronic health record or SureScripts, which is allowing better informed drug selection. As health information exchanges (HIEs) evolve, those lists can be brought together in a more informed way. In the patient side, “personal medication assistant” technologies exist to make sure the medications are administered and that they are helping the patient. Another set of devices can feed data into a dashboard so that the care manager can efficiently communicate with the Patient. Cellphone technology can also help monitor the patient.

For the future, the group members agreed that merged medication lists can draw data from various points, connect the physician to the electronic medical record, so the caregiver will know what medications were prescribed and know whether the prescriptions were filled. This will allow the caregiver to sit with the patient and negotiate with the patient what they will take. Today medication reconciliation takes place but not in a coordinated way.

Information flow: This group identified information flow from ambulatory care to the medical home and the information flow across the medical home. While the patient is in the hospital, the caregiver may not have access to the discharge process, and to communicate in a timely manner with those across the medical “neighborhood. Currently there’s a lack of IT solutions that create a seamless experience. There is a need to “bring together building blocks of technology, process and incentives” in a way that can be replicated across communities. There is a need to specify IT solutions and assemble them into building blocks in a way that makes sense in different care scenarios. The bottom line is that although technology exists for improving communication, there is a need to improve communication between points and people who work with patients and family members.

One concrete example is that patients often give vague information when asked about his primary care physician. A solution, known as “iPIPE,” under development at Johns Hopkins University, automatically reaches out to probable PCPs and allows the PCP to self identify and communicate with the hospital in a HIPAA-compliant way to confirm the provider is the patient’s PCP.

The group also advocated central care plan for the patient, in which all caregivers, as well as the patient, collaborate.

Patient and caregiver activation: This group identified several key themes: identify a core care team to prepare the patient; understand the patient’s preferences, needs, and unique circumstances; identify high readmission areas in the hospital that need attention; set expectations for patients, family caregivers, and making sure that they are doing what they are supposed to do at every point in the care process; and identify who is responsible at every stage in the process.

Among its recommendations for the future, this group said the patient’s central care plan needs to be available to all stakeholders, and be included in the patient record. Use rich media such as audio and video to inform patients and share information with other patients. Put actionable data into the patient record, with feedback loops, allowing members of the care team to monitor care and measure outcomes.

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