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

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Summary:

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.

Evaluation of Effectiveness of a Health Information Technology-Based Care Transition Information Transfer System - 2012

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS08-002: Ambulatory Safety and Quality Program: Improving Management of Individuals with Complex Healthcare Needs Through Health Information Technology (MCP)
  • Grant Number: 
    R18 HS 017864
  • Project Period: 
    September 2008 – September 2012
  • AHRQ Funding Amount: 
    $1,155,371
  • PDF Version: 
    (PDF, 223.07 KB)

Summary: Improving communication between inpatient and outpatient providers will be crucial as the health care environment continues to shift and the burden of patient care is spread across settings. Changes in health care include imposed payments for avoidable readmissions, the development of patient-centered medical homes, accountable care organizations, and bundled payments. Each will present challenges to health care organizations struggling to adapt, adjust, and remain viable. New ways to improve communication through use of health IT must play a central role in this process.

The purpose of this project was to improve the coordination of care for patients with two or more chronic conditions who were discharged from a hospital to a rural primary care clinic. The project team developed and implemented a care transition information transfer (CTIT) system for all Billings Clinic Hospital discharged patients and post-acute care providers, with a particular focus on those living in rural communities. The CTIT system was designed to pull patient data from the Billings Clinic integrated electronic health record (EHR).

Primary care clinics within and outside the Billings Clinic health care system receive notifications by efax, providing basic data on the recent hospitalization, followup appointments, and medications. Internal providers may also receive notification through the EHR messaging system. Outside providers are prompted to access more complete medical information by connecting through a Web-based portal to the hospital’s EHR. The system provides patients and their primary care providers (PCPs) with discharge information, including a patient-friendly medication list, as well as information about followup visits, laboratory testing and results, and operative reports.

Dr. Ciemins and her team conducted a prospective study to evaluate whether development and implementation of the CTIT system improved patient and rural provider satisfaction with the hospital discharge process, and to measure system efficiency and process outcomes, as well as patient clinical outcomes. 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. A second intervention modified the EHR-based medication reconciliation process. Secondary outcomes included medication reconciliation, patient medication adherence and accuracy, and patient and provider satisfaction.

Study participants included medically complex adults discharged from an urban hospital to their rural homes. These medically complex adults were defined as those managing at least two of the following chronic conditions: depression, diabetes, hypertension, heart failure, chronic obstructive pulmonary disorder, coronary artery disease, transient ischemic attack, or cerebrovascular accident. A total of 1,197 patients were randomly selected from 4,300 eligible patients from 185 rural health centers.

Specific Aims:

  • Develop a health information technology-based CTIT system. (Achieved)
  • 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. (Achieved)

2012 Activities: A new medication reconciliation process was implemented in May 2012 and the research   team collected the final round of data for this process. All nursing staff members were trained on the computer-based medication history update that comprises the first part of the reconciliation process; all physicians were trained to do an admission and discharge medication reconciliation. As in prior data collection phases, participants were randomized from a list of patients who were diagnosed with two or more chronic conditions.

This final data collection phase involved selecting a total of 25 patient interviews per month, for a total of 100 calls over 4 months. Patients were called within 30 days of discharge. Pharmacists called patients and recorded information. Data were then reviewed by the research team, and an expert reviewer confirmed whether each medication was reconciled. Expert reviews were done by comparing the discharge summary, the medication list, the patient-friendly medication list, and patient report. Considerations included the time that each list was completed and when the call with the patient took place, whether short-term drugs remained on these lists, and whether selections were still accurate. They also assessed whether patients were taking the correct medications in the correct dosages at the correct times. When discrepancies were found, it was noted as to whether it was due to patient error, a conscious decision by the patient to change how s/he took the medication, or a reconciliation error. Medical chart reviews were conducted on all participants to confirm the Billings Clinic visits and hospitalizations reported by the patient.

During 2012, Dr. Ciemins’ team also focused on data analysis and manuscript preparation. The project used a 1 year no-cost extension to complete the project which ended in September 2012. As last self-reported in the AHRQ Research Reporting System, progress was completely on track and budget spending was on target.

Impact and Findings: The results of this study demonstrate how a health IT intervention, focusing on discharge standardization and improved provider communication, may improve followup of medically
complex patients post-hospitalization and lead to reductions in readmissions. Sixty-three percent of patients at baseline compared with 75 percent of patients post-intervention received a medical followup appointment within 30 days of hospital discharge. Further, receiving a medical followup visit within 30 days was associated with reduced readmission rates and post-discharge emergent care visits. Improvements were also observed in EHR medication reconciliation at discharge and during followup, accuracy of information collected at admission, and completeness of patient discharge medication list. Provider satisfaction with the efficiency and reliability of the care transition process improved over time.

Target Population: Adults, Chronic Care*

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Implementation and Use

* This target population is one of AHRQ’s priority populations.

Evaluation of Effectiveness of an Health Information Technology-based Care Transition Information Transfer System - 2011

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS08-002: Ambulatory Safety and Quality Program Improving Management of Individuals with Complex Healthcare Needs through Health Information Technology (MCP)
  • Grant Number: 
    R18 HS 017864
  • Project Period: 
    September 2008 - September 2012
  • AHRQ Funding Amount: 
    $1,155,371
  • PDF Version: 
    (PDF, 205.3 KB)

Summary: This project seeks to improve the coordination of care for patients with two or more chronic conditions who are discharged from a hospital to a rural primary care clinic. The project team has developed and implemented a Care Transition Information Transfer (CTIT) system for all Billings Clinic Hospital discharged patients and followup providers, with a particular focus on those living in rural communities. The CTIT system will pull patient data from the Billings Clinic integrated electronic health record (EHR).

Primary care clinics within the Billings Clinic integrated health system are notified of their discharged patients directly through the EHR. Primary care clinics outside the system receive notifications by e fax or email, providing basic data on the recent hospitalization, followup appointments, and medications. These providers are prompted to access more complete medical information by connecting through a Web-based portal to the hospital's EHR. The system provides patients and their primary care providers (PCPs) with discharge information, including a patient-friendly medication list, as well as information about followup visits, laboratory testing and results, and operative reports.

Project staff are conducting a prospective study to evaluate whether development and implementation of the CTIT system has improved patient and rural provider satisfaction with the hospital discharge process, and to measure system efficiency and process outcomes, and patient clinical outcomes. Patient clinical outcomes include 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. Clinical outcome data have been collected at three data points: baseline data were collected on 400 patients between October 2008 and August 2009, and post-intervention data were collected between April and December 2010 (401 patients), and from August 2011 to January 2012 (295 patients).

Specific Aims:

  • Develop a health information technology-based CTIT system. (Achieved)
  • Evaluate the effects of the CTIT system on: (Ongoing)
    • Clinical and systems-level outcomes. (Ongoing)
    • System efficiency. (Ongoing)
    • Satisfaction with care transitions among rural PCPs. (Ongoing)
    • Patient satisfaction with care transitions. (Ongoing)
    • Timely communication of patient information. (Ongoing)

2011 Activities: During the first quarter of 2011, the research team completed data collection for the intervention period. The final medication reviews, to verify the accuracy of patient-friendly medication lists distributed at discharge and EHR medication lists at time of telephone call were conducted via telephone and chart review by research nurses and pharmacists. A total of 400 chart reviews were completed by registered nurses who have specific experience in medication assessment. In addition, 400 patient satisfaction surveys were sent and 154 returned, and 400 post-intervention-period telephone interviews were completed.

In July 2011, the project went live with the distribution of the Clinical Summary Form in the Housewide Depart (HWD) process. The HWD is a nurse-driven checklist that includes both patient and provider discharge information. This means that when any patient with a listed PCP is discharged from the hospital, the PCP will be notified that his/her patient has been in the hospital. Prior to this, only patients discharged by a participating hospital had a note sent to their PCP. This represents an increase from reaching 15 to 20 percent of discharged patients to approximately 80 percent.

The post-intervention round of data collection began in September 2011, and will continue into early 2012. So far, 194 patients have been called; therefore, Dr. Ciemins and her research team reached the goal of conducting 50 calls per month. The purpose of these calls is to assess followup health care utilization, education received, medication reconciliation, and medication correctness (i.e., whether medications are being taken correctly). The post-intervention round of expert medication reviews is also on track, and by December 2011, reviews had been completed on 68 of the 80 patients who had been targeted for this review.

In fall 2011, Dr. Ciemins embarked on a new collaborative effort with the Community Care Transitions Project (CCTP), led by the Quality Improvement Organization for Montana (Mountain Pacific Quality Health). CCTP is particularly interested in Dr. Ciemins' research in the area of transitions to non-hospital care settings because Billings Clinic Hospital is widely considered to be one of the most progressive hospitals in the region in terms of care transitions. CCTP is organizing community organizations, including assisted living and nursing homes throughout the area, and looking at transitions to other care settings in addition to patients' homes. The Billings Clinic Center for Clinical Translational Research is leading activities to identify measures and outcomes of care transitions.

As last self-reported in the AHRQ Research Reporting System, project progress and activities are on track and project spending is on target. Dr. Ciemins is using a 1-year no-cost extension to ensure adequate time to complete data collection, medication reviews, and data analysis.

Preliminary Impact and Findings: A total of 150 PCPs completed surveys on their satisfaction with the discharge process at baseline and following the intervention period. Post-intervention results showed that 63 percent of providers found the discharge process to be efficient and reliable, resulting in quality patient care, compared with 38 percent at baseline. Substantial improvements were also shown when providers were asked whether information was sufficient and timely, and when asked about whether they and their patients were provided with reconciled patient medication lists.

Target Population: Adults, Chronic Care*

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Implementation and Use

* This target population is one of AHRQ's priority populations.

Evaluation of Effectiveness of an Health Information Technology-based Care Transition Information Transfer System - 2010

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS08-002: Ambulatory Safety and Quality Program Improving Management of Individuals with Complex Healthcare Needs through Health Information Technology (MCP)
  • Grant Number: 
    R18 HS 017864
  • Project Period: 
    September 2008 – September 2011
  • AHRQ Funding Amount: 
    $1,155,371
  • PDF Version: 
    (PDF, 374.13 KB)


Target Population: Adults, Chronic Care*, Rural Health*

Summary: This project seeks to improve the coordination of care for patients with two or more chronic conditions who are discharged from a hospital to a rural primary care clinic. The project team will modify the current Billings Clinic electronic health record (EHR) system, the Certification Commission for Health Information Technology-certified Cerner EHR, to develop, implement, and evaluate a Care Transition Information Transfer (CTIT) system for all Billings Clinic Hospital discharged patients and followup providers, with a particular focus on those living in rural communities.

Primary care clinics with EHR-integrated systems will be notified of their discharged patients directly through the Billings Clinic EHR. Primary care clinics outside of the system will access the EHR through a Web-based portal and through the receipt of e-fax, e-mail, or phone messages. The system will provide patients and their primary care providers (PCPs) with discharge information, including medication management, followup visits, laboratory testing and results, and operative reports. Project staff will conduct a prospective study to evaluate whether the intervention improved patient clinical outcomes, system efficiency and process outcomes, and patient and rural provider satisfaction with the hospital discharge process.

Specific Aims:
  • Develop a health information technology-based CTIT system. (Achieved)
  • Evaluate the effects of the CTIT system on:
    • Clinical and systems-level outcomes. (Ongoing)
    • System efficiency. (Ongoing)
    • Satisfaction with care transitions among rural PCPs. (Ongoing)
    • Patient satisfaction with care transitions. (Ongoing)
    • Timely communication of patient information. (Ongoing)

2010 Activities: Project staff completed the standardization of the discharge process through the development of an EHR-based discharge tool called Housewide Discharge (HWD), which is essentially a nurse-driven checklist and includes both patient and provider discharge information forms. All testing and refinements were completed on HWD, which went live in April. Patients were also asked to complete satisfaction surveys, with 38 returned so far. Admission, discharge, and transition nurses met with the team and provided substantial feedback, which was addressed. A notification for primary care providers was initiated by the Hospitalist Department. The team continues to work toward an automated notification process, which will increase the reach of notification-receiving providers.

In collaboration with their information systems department, project staff developed these notifications for PCPs, called Discharge Power Notes, which are automatically sent to PCPs via fax or EHR message center. Between October 2009 and September 2010, 1,109 PCP notifications were sent by 15 hospitalists to 203 PCPs in the region. All of these providers were also sent PCP notification satisfaction surveys including a solicitation for process and content improvement suggestions.

The team completed 300 of 400 of the intervention period chart reviews via telephone by registered nurses who have specific experience in medication assessment. Analysis and expert medication reviews continue, with 126 of 300 completed to date, and remain a focus of the project.

Reliability and validity testing for transfer of information to both patients and providers was completed. This illuminated some data quality issues that were then reported back to clinical discharging staff. System modifications were made and additional training of discharging staff took place.

Grantee’s Most Recent Self-Reported Quarterly Status (as of December 2010): The HWD went live in April. PCP notifications continue, as do intervention period chart reviews, expert medications reviews, and data analysis. Progress is mostly on track, and budget spending is roughly on target.

Preliminary Impact and Findings: Seventy-six PCPs completed a survey on their satisfaction with the health information technology discharge notification tool. All but one respondent reported that they wanted to know when their patients were discharged from the hospital, and of those who received a notification, nearly all reported that they then consulted the patients’ EHR. Preliminary data on 300 patients included an increase in PCP followup visits within 30 days of hospital discharge, and a decrease in post-intervention readmission rates.

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Implementation and Use

*AHRQ Priority Population.

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

Citation:
Ciemins, E. Evaluation of Effectiveness of an Health Information Technology-based Care Transition Information Transfer System - Final Report. (Prepared by the Billings Clinic under Grant No. R18 HS017864). Rockville, MD: Agency for Healthcare Research and Quality, 2012. (PDF, 830.22 KB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
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