Care transitions has different workflows implemented by care providers. They can help with a variety of problems related to medicine reconciliation, efficiency, and safety of the patients. There was one study done where the care providers applied a transitional care management service led by a nurse care manager. A team developed a workflow using a Plan-To-Do-Study-Act cycle for communicating with patients. The study showed progress in following up with patients that had visited the facility 7 to 14 days prior to the phone call. This workflow process was effortlessly implemented in a primary care practice.

I visited the AHRQ Health IT website and looked through the different kinds of workflow tools that can be used to obtain and analyze workflow information. One tool that I believe could resolve an informatics issue in care transitions is a flowchart. A flowchart is a workflow tool that visually delivers the steps in a certain process. Many people see and understand certain data when it is visual rather than in data points. One issue in care transitions is having high readmission rates in facilities. To have low readmission rates, it is important to give proper care during and after the visit. Doctors have many tasks to accomplish every day, and some mundane tasks might be missed. Implementing a workflow flowchart to remind doctors to follow up with their patients after discharge will lower readmission rates. The visually engaging tool will also help in identifying areas for improvement in the process.

Human factors and ergonomics is the understanding of interactions among humans and other elements of a system, and the profession that applies theory, principles, data, and other methods to design in order to optimize human well being and overall system performance (IEA, 2000). The level of HFE work investigating the components of care transitions is low. However, research shows that HFE can diminish risk in patient readmission and provide a smooth transition by health care workers educating the patients on self-care after discharge. The technological tools and services the patients will use to understand their sickness must be user friendly and comprehensible to them. These tools could be mobile applications or website portals for that specific health facility. Charts, lab results, and visual imaging should have descriptions and summaries that are easy to understand by the patients. It is important to implement HFE in patient care because they need to take care of themselves properly after discharge. Having the right tools to do this will decrease readmission rates in facilities, improve the health of the patients, and create efficiency in one aspect of care transitions.

Resources:

“Flowchart.” Flowchart | AHRQ Digital Healthcare Research: Informing Improvement in Care Quality, Safety, and Efficiency, digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/flowchart.

Holden, Richard J., and Ephrem Abebe. “Medication Transitions: Vulnerable Periods of Change in Need of Human Factors and Ergonomics.” Applied Ergonomics, Elsevier, 10 Oct. 2020, www.sciencedirect.com/science/article/pii/S0003687020302283.

Steckbeck, Julia, et al. “Implementation of a Workflow Initiative for Integrating Transitional Care Management Codes in a Geriatric Primary Care Practice.” Journal of Nursing Care Quality, U.S. National Library of Medicine, 2018, www.ncbi.nlm.nih.gov/pmc/articles/PMC6013313/.

Public health informatics, or PHI, is defined as the systematics application of information and computer sciences to public health practice and research. The focus of PHI is to promote health of populations, not individuals. It is a policy or system used throughout populations to improve them. PHI is seen in areas of public health involving surveillance, health promotion, prevention, and preparedness. It is also used quite often in transitional care to promote health and minimize problems in many hospitals, clinics, etc. The improvement of care transitions is significant for stakeholder groups, hospital directors, and hospital doctors. There are hospitals, and other health facilities, that work together and are part of a greater organization. In this case, the healthcare workers must integrate systems and procedures for a smooth transition. Stakeholders of such facilities make decisions that will affect all the facilities included as a whole. These goals are included in the National Quality Strategy.

Guaranteeing consistent and high-quality transitional care has been difficult for many health organizations nationwide. A study of 29 respondents from 17 different organizations was done to see how care transitions is doing well and what aspects can be improved. Respondents stated that HIT in care transition is used to monitor patients and align systems resources with population needs. One area of to improvement is in interoperability. Lack of interoperability leads to ineffective processes and missing data.

Telehealth is the use of digital information and technology to access health care services. Communication technologies, such as mobile phone and computers are used. Healthcare workers conduct phone calls and in person visits to make sure everything is on track with the patient post discharge. However, telehealth is used instead of in person visits when it is difficult for the patient to visit the care facility. Health facilities have their own telehealth services. Some facilities have a mobile application to track post discharge progress of patients. Synzi is a virtual care application that bridges the gap between clinicians and patients. Please see the uses of Synzi below.

1. Use video to check-in with patients, share patient education, and answer questions in real-time. Multiple care team participants – and the patient’s family caregiver and a medically-certified interpreter – can be included in the virtual visits to ensure alignment on the next phase in the continuum of care.
2. Deliver a cadence of ongoing messages which drive better patient understanding of one’s condition(s) and medication adherence. The messaging can be personalized to reflect the patient’s multiple conditions and translated into the patient’s primary or preferred language.
3. Leverage assessments and RPM technology to monitor patients on a regular basis. Clinicians can gain insight into the patient’s progress in between visits and explore if the plan of care may need to be changed or if the patient’s change in condition necessitates a more immediate intervention.

As mentioned above, interoperability needs to be improved in care transitions. Patients attend different hospitals, clinics, and specialists for chronic conditions, so providers need an efficient and consistent way to gain access to data and exchange information accurately and securely. The Health Information Technology for Economic and Clinical Health Act of 2009 brought significant investments to health IT. Incentives are given to hospitals and eligible professionals who meaningfully use EHRs, and they encourage facilities to share their patient data with other facilities. EHR use has increased since 2009, however, the level of electronic information exchange is not high enough.

The requirements and meaningful use standards to use EHR technology are quite limited. I believe that the standards should be restated and less limited to make health information exchange easier and safer to use by healthcare providers. Surveys should be done by these providers to see what information truly should be sent out according to the type of health provider. Also, cutting the costs of EHRs and providing comprehensive training to use the systems will increase serviceability.

The Federal Health IT principles lay out rules for federal agencies to collaborate on with state, local, and private stakeholders. One policy that relates to care transitions is to focus on value and continuously target solutions that improve health, efficiency, safety, affordability, and access. Another important policy is to build a culture of electronic health information access and use. This is something providers are striving to accomplish each day and will improve HIT significantly. Also, encouraging innovation and competition will help spread knowledge and improvement upon providers.

Resources

EHRIntelligence. “How Interoperability Drives Care Coordination Over Care Continuum.” EHRIntelligence, 11 Nov. 2019, ehrintelligence.com/news/how-interoperability-drives-care-coordination-over-care-continuum.

“How Telehealth Supports Transitional Care Management (TCM).” Synzi, 15 July 2020, synzi.com/blog/how-telehealth-benefits-transitional-care-management/.

“Managing Your Health in the Age of Wi-Fi.” Mayo Clinic, Mayo Foundation for Medical Education and Research, 15 May 2020, www.mayoclinic.org/healthy-lifestyle/consumer-health/in-depth/telehealth/art-20044878.

Samal, Lipika, et al. “Care Coordination Gaps Due to Lack of Interoperability in the United States: a Qualitative Study and Literature Review.” BMC Health Services Research, BioMed Central, 22 Apr. 2016, www.ncbi.nlm.nih.gov/pmc/articles/PMC4841960/.