Care transitions is as much of the responsibility of the doctor as it is of the patient and family caregivers. This is seen when a patient is being discharged to go home from a care facility. There is frequently post discharge care that needs to be completed by the patient and the patient’s family caregivers. Sometimes these measures are small, especially for small procedures or non-life-threatening injuries. However, the measures can be intensive and long for patients with chronic conditions. Taking both types of measures will decrease health complications and re-hospitalization. Caregivers should leave the care facility knowing what medications the patient needs, what side effects to look out for, what the patient can and cannot do, etc. The caregivers need to discuss all of this with the doctor and pharmacist and keep them in the loop for progress or even red flags in the patient’s health. The family caregivers should have a way to track down the patient’s health on a website or app that will be shared with the doctor. The caregivers can also have a medication list and reminder set up through the app to make it easier.
A consumer health informatics issue seen in transitional care is quality and access. Unfortunately, everyone cannot receive the same level of treatment, resources, and access to technological equipment needed for their health. People living in underprivileged areas may not have access to websites and mobile applications that can help keep their post discharge treatment on track. Also, they may not have the money to buy home devices and equipment needed to monitor their health. Quality of care is also an issue due to less facilities with proper resources in these impoverished areas. Care providers should keep this in mind when recommending web resources and technologies to patients. They could print out the information and put it in a organized folder for the patient instead of online resources. They could also have equipment that can be borrowed or bought for a lower price in the facility.
There are many different technological advancements in care transitions. One of these technologies include DrFirst, a telehealth mobile application that will close the gaps between information and people for all sectors of healthcare to have better outcomes together. It is a collaboration between EHRs, hospitals, pharmacies, patients, caregivers, pharmaceutical companies and more. Prescription drug monitoring programs (PDMPs) are mandated at state level so prescribers can identify patients who are addicted, or at risk of being addicted, to dangerous drugs. Smartwatches are another example of devices that can keep track of patients’ health data. Since the patient can upload the data and share it with whomever they want, there are no legal mandates.
Though care transitions has progressed a fair amount since the start of technological advancement the past decade, it still needs a lot of improvement. Since interoperability is such an important concept for transitional care, I hope it will have enhanced a lot in the next 5 to 10 years. Its enhancement will make data in EHR systems easily ready for any physicians operating it. With the continual advancement of technology, I am sure there will be new telehealth systems and applications that will be post discharge care easy to track, maintain, and share. Home based health devices will be widely used with more virtual doctor visits rather than in person visits. Economic factors are the biggest driving force to motivate change in transitional care. Poor transitional care equates to high rehospitalization rates. This causes unnecessary extra bills for the patient to pay, and a waste of time, efficiency, money, and resources for the care facility.
Please see my care transitions concept map above. It starts with the patient and then goes to the doctor the patient goes to see. The doctor gets the PHI and puts it in an EMR. However, the doctor still needs to see the patient’s other health records before making any decisions. That is why the map also includes other care providers the patient has gone to before. The doctor will get that data through the EHR system. Once the doctor has all the PHI needed, they will run tests if needed and then make a treatment plan. Once the patient is tended to, the doctor will use mHealth to provide the treatment plan, medications information, services, to the patient. From there, the patient will either go to post op care, a secondary facility, or be home discharged. The patient and doctors will then monitor, assess, educate, and coordinate the health of the patient.
The first thing I learned in class was how complex the healthcare system is in America and how there is still a long way to go to get a universal, proper system. Just learning about the importance of health informatics in the healthcare field showed me how challenging and rewarding it is. Learning about how advanced technology has improved parts of health informatics makes me excited to see what new and improved systems and concepts will come next. Health is something that immensely affects everyone in the world. Even if there is a possibility to change one small thing, that will help make healthcare better in the long run.
Resources:
https://drfirst.com/
https://www.commonwealthfund.org/publications/newsletter-article/avoiding-preventable-hospital-readmissions-filling-gaps-care