Evaluation of Effectiveness of a Health Information Technology-Based Care Transition Information Transfer System

Reducing readmissions and improving care transitions from hospital to home has become a priority for health care organizations seeking to improve quality and reduce costs. Medically complex patients, defined as those who have two or more chronic conditions, are at increased risk for readmission. This is particularly true for patients in rural communities whose providers may not be aware of hospital stays and followup needs. Lack of communication between inpatient and rural providers may contribute to rural patients' not having appropriate followup post-discharge, increasing their risk of avoidable readmission. 

This project developed, implemented, and evaluated a care transition information transfer (CTIT) system to improve provider-to-provider communication and standardize the discharge process. This standardized process included: 1) modifying the current electronic health record (EHR) system to institute an electronic discharge “check list”; and 2) communicating key patient discharge information to rural primary care providers (PCPs). In addition, the project modified the EHR-based medication reconciliation process to improve the accuracy of the reconciliation process and the discharge medication list.  

The main objectives of this project were to:

• Develop a health information technology-based CTIT system.
• Evaluate the effects of the CTIT system on: clinical and systems-level outcomes; system efficiency; satisfaction with care transitions among rural PCPs; patient satisfaction with care transitions; and timely communication of patient information. 

A prospective study of 1,197 medically complex patients from 185 rural health centers was conducted to evaluate whether the CTIT system improved patient and rural provider satisfaction with the hospital discharge process; to measure system efficiency and process outcomes; and to measure patient clinical outcomes. The patient clinical outcomes included patient adherence to medication instructions after discharge, patient receipt of reconciled medication lists, hospital readmission rates, ambulatory followup visits, and utilization of emergent care services. 

The CTIT system was found to have many beneficial outcomes. The rate of followup visits within 30 days of discharge increased from 63 to 75 percent. Those who had a followup appointment were 44 percent less likely to be readmitted to the hospital and 75 percent less likely to visit the emergency room. Medication reconciliation at discharge and during followup significantly improved as did the accuracy of information collected at admission and completeness of the patient discharge medication list. Over time, provider satisfaction with the efficiency and reliability of the care transition process improved.