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

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/.

EBP, or evidence based practice, is a problem solving approach to clinical practice. Some examples of EBP are real world practice, research, and innovations that emerge through research and practice. External evidence is generated through research, and internal evidence is generated through outcome management and practice based evidence. Informatics is a concept that is needed for EBP. Many healthcare workers and clinicians hire health informatics experts to help with the EBP process in their clinic or hospital. The PICO(T) method is used to support EBP. It is also important to acquire evidence, appraise the evidence, and apply the evidence found.  Quality improvement/process improvement, QI and PI, are used by informatics professionals to improve systems and processes in order to improve the result.

Poorly coordinated care transitions from a hospital to other care settings cost an estimated $12 billion to $44 billion per year. A few adverse effects due to inadequate transitional care are medication errors and procedure complications. There are certain guidelines clinics have implemented that reduced readmissions and costs. One existing guideline is comprehensive discharge planning. Physicians, nurses, or other medical staff organize follow up services prior to patient discharge. They discuss any financial or psychological barriers a patient may have and use community resources to help if needed. The staff call the patient about one to three days post discharge to assess any new symptoms and answer questions.

Another successful program is the Transitional Care Model, which was practiced in six Philadelphia hospitals between 1997 and 2001. Advanced transitional care nurses visited chronically ill patients’ homes about 8 times and were on call by phone seven days a week. After one year, this practice reduced readmission rates by 36% and net costs by 38%. Informatics is a necessity for quality improvement of care transition. Storing, managing, and translating data into knowledge for the, providers, patients, and their families will improve the efficiency of care transition and cut overall costs.

Informatics professionals can use data mining to further assist healthcare workers on improving certain EBP programs. When using the transitional care model, I would gather data by conducting and comparing patient satisfaction and level of comprehension surveys after their visits I would see if there are patients with certain illnesses that need more care and education than others during and after discharge. I would use the tool Tableau to visualize the data. EHRs are a cloud-based system and have different computer format capabilities. Having EHRs is important in care transition because it gives medical staff access to patient records from all clinics and hospitals. This eliminates duplicate tests and ultimately reduces costs. I would use EMRs to clearly identify the patient medical history and any new history since the last visit. I would use EHRs to compare that data across all providers to properly assess the best care and medications needed for the patient. If EHRs are not being used it could cause problems in giving the best care to the patient.

Clinical Decision Support, or CDS, is a process used to improve health related decisions and measures. There are different opportunities that can be integrated to care transition. One is medication management to improve medication use and results. The goal is to cut extra medication costs, transition efficiently, and optimize patient care. It is crucial to educate the patient on the medication for more self-care. Usually a nurse, pharmacist, physician, patient, and other care providers will be would be following the guidelines. This data will be provided in EMRs, PHRs, and pharmacy systems. The tracking of the effects of medication can be done through the health provider website or a mobile app. Those two options would be the easiest and most effective for the patient and care providers.

Resources

https://chrt.sites.uofmhosting.net/wp-content/uploads/2014/01/CHRT-Care-Transitions-Best-Practices-and-Evidence-based-Programs-.pdf?_ga=2.204112080.1705035215.1601513958-1780368870.1601513958

https://averytelehealth.com/health-plan/

https://digital.ahrq.gov/ahrq-funded-projects/current-health-it-priorities/clinical-decision-support-cds/chapter-1-approaching-clinical-decision/section-4-types-cds-interventions

Informatics is the study of computational systems and information processing. It is to transform information and data into knowledge, so it is accessible to anyone in need. The transition of information into knowledge should help the people in need by creating a new process or making an existing process better. Informatics is an umbrella term for other specific studies, and health informatics is one part of it. There are many interesting topics under health informatics, but one topic I am very interested in is care transitions.

Care transitions, also known as transitional care, are services patients receive to have a safe and effective hand off between heath care facilities or even for discharge to go home. Care transitions is an important step in the healthcare process for both the patients and providers. These services are usually time sensitive and the correct medical history and information needs to be conveyed to all doctors and nurses seeing the patient across all facilities. Care transition can affect older patients that have to move through facilities a lot and acute care patients. There are times when all the medical history is not transferred properly through all the doctors and this can cause an error in the patients’ diagnosis and treatment. Due to the hospital’s ineffectiveness and lack of organization, patients could be waiting to be discharged longer than necessary and be billed for all the extra days. This may cause the hospitals profit to briefly increase, but it causes the patients satisfaction to decrease.

I believe one way to increase effectiveness is to design a mobile application that will give the patient and the doctors all the same information. This information includes contact information of other facilities, discharge information and schedule, lab reports, and so on. The application can also have future appointment dates and test dates in a calendar and any notes included by the doctor on more specific treatment plans. This is an informatics challenge because it relates back to the definition. There are many systems in place for care transitions, but there are always ways to make the systems more effective. Using informatics for care transitions helps transform all the medical information and present it to the patients and providers in a way that is easy for everyone to access and understand.

An article by Mackenzie Bean, a writer for the Becker’s Hospital newsletter, called 4 strategies to improve care transitions, really opened my eyes about a few problems that occur in care transition. The article focuses on post-acute care patients and the challenges they face that are out of their control. Jay LaBine, a MD and Spectrum Health, stated that he realized something was wrong when a veterinarian took more time to discuss the post care instructions with him about his dog than a physician spends with a patient to discuss their care after discharge. The article then addresses that Doctor Jay LaBine partnered with naviHealth to manage the hospital care transitions better. Mackenzie goes on to communicate why there is a strong need for care transitions and how to improve it. The article discusses the need for a patient care model rather than a business model. It was crucial that the hospital staff assess the patient’s medical history and treatment as precisely as possible to review the post-acute care instructions, length of stay, and discharge dates. Progress was made once doctors from different facilities discussed the patients care and proactive discharge was planned.

Welcome to my blog. I will be discussing the importance of Care Transitions in Health Informatics.

Thank you for visiting!