Saturday, October 8, 2011

Putting the 'IT' in Care Transitions

Healthcare transitions which are not well coordinated can lead to emergencies, higher costs and lower quality. This is a big problem. Breaking the cycle of hospitalization, nursing home admissions, home health visits, followed by repeated hospitalizations, then spiraling into decline with eventual death is something we must do. In the case of my mother the last years of her life went through this revolving door with very high mental, emotional and financial costs.

A study published recently in The New England Journal of Medicine, confirms what many of us have observed: health care transitions, such as moves in and out of the hospital from a nursing home, do not lead to positive outcomes. More common are frequent medical errors; poor care coordination, infections and additional medications. For patients with acute dementia, these transitions can exacerbate already present symptoms such as agitation, confusion and emotional distress. But improving care transitions is important for everyone.

On Friday, October 14th, 2011, a group of innovators, policy and health IT experts, healthcare providers, patient organizations, technology companies, and government agencies will gather in Washington, D.C. to assess progress in improving transitions in care and to prioritize how better use of health IT can address some of the most difficult challenges related to care transitions on a broader scale. Conference participants will identify:
  • Best practices using health IT that can be implemented immediately to improve care transitions
  • Best practices that can be implemented within a year 
  • A research agenda focused on finding solutions to persistent barriers to further progress.
As a wonderful example of using government as a platform, the John A. Hartford Foundation, the Gordon and Betty Moore Foundation, and Kaiser Permanente, with the Office of the National Coordinator for Health IT and the Beacon Communities as key participants, are convening this event. Portions of the event will be webcast and there will be active discussion on Twitter and Google Plus. One goal is to encourage debate and interaction among all participants about this important subject through social and traditional media, before, during and after the meeting. Sign up for registration HERE, look for the hashtag #ITrans, and join in the conversation.

The event will focus on a set of prominent drivers of errors that are major opportunities for improvement by better using technology. There will be breakout session during the event on each of these levers. They are:
  1. Discharge process 
  2. Medication reconciliation 
  3. Information flow/exchange 
  4. Patient and care-giver activation
One of the aims of the event will be to coordinate and align multiple ongoing efforts related to transitional care interventions, with a special focus on the role of health IT in improving transitional care interventions. We will also review the most promising transitional care levers and attempt to achieve consensus among experts and practitioners about the most important characteristics or practices currently available. There will be an effort to identify current problems or constraints within each lever and specific actionable steps that can be taken by government, foundations, and the private sector to foster greater innovation/development. Strategies for spreading promising IT-enabled models, and barriers outside the realm of HIT will also be explored.

As HHS CTO Todd Park said, "Care transitions are difficult for patients and families for many reasons. If we can clearly identify the most challenging issues, for which no solutions exist today, we will provide much needed focus to innovators and investors across the country who are energized to improve care for patients, and systems of care for providers."

Some of the speakers participating in the event will be: National Coordinator for Health IT, Dr. Farzad Mostashari; Todd Park, Chief Technology Officer of HHS; Dr. Aaron McKethan, ONC Director of the Beacon Community Program; Dr. Eric Coleman, creator of the Care Transitions Intervention; Dr. Joanne Lynn, Altarum Institute; Carol Beasley, Institute for Healthcare Improvement (IHI) and Health Affairs Editor-in-Chief, Susan Dentzer.

Using technology to improve care transitions can have an incredible impact, not only on outcomes but eventually also on the cost of care. Health IT will be key to improving quality by better coordinating care across the healthcare continuum. “By expanding the smart use of health information technology during transitions, we are paving the way for smarter, lower-cost health care and new levels of sustainable health care quality,” said George Bo-Linn, MD, Chief Program Officer of the San Francisco Bay Area Program with the Gordon and Betty Moore Foundation. “This kind of large-scale, systemic change has the potential to make a difference in people’s lives that will be both lasting and significant.”

“With our eyes on the prize to ensure seamless transitions, we are pursuing a range of aligned strategies including standards, interoperability, exchange and provider adoption and meaningful use. Through our programs, we need to deeply understand and spread the simple yet powerful HIT-enabled solutions that address the complex problem of care transitions,” said Farzad Mostashari.

Care transitions refer to any movement patients make between practitioners and health care settings, but for the purpose of this meeting, are defined as hospital to post-hospital. Hospital readmissions, one common outcome of an unsuccessful transition, are extremely expensive: one in five Medicare patients is back in the hospital within 30 days of discharge, at the cost of approximately $17 billion per year, and many of these readmissions are considered avoidable.

“All health care providers understand both the human need to improve the patient experience during transitions of care, as well as the new demands that Medicare and others will be placing on systems to improve transitions. This meeting is an important service to anyone trying to create patient-centered transitions that are high quality, safe and efficient,” said Scott Young, MD, Associate Executive Director of Clinical Care and Innovation at Kaiser Permanente.

“It is increasingly clear that health information technology, implemented in a patient-centered way, has vast potential to help us reduce the number of injuries, accidents and re-hospitalizations that are causing stress and harm to patients, particularly older patients, every year,” said Christopher Langston, PhD, Program Director of the John A. Hartford Foundation. “We are committed to helping identify and support the best examples of health IT to assist complex patients in their most vulnerable moments.


  1. The government should think of ways to innovate the healthcare industry. thanks to this blog!

  2. Thanks for this synopsis, Brian. Look forward to hearing more about it at Health Camp Oregon on Oct. 22nd. I hear you'll be there?

    Very interested in this and am helping to start a project to solve some of these. I look forward to hearing your thoughts and feedback.

  3. Thanks Leonard, I look forward to seeing you at Health Camp Oregon!