How to Improve Patient Safety during Transitions of Care

Poor communication and incomplete information increase the risk of adverse events during transitions of care. The use of an integrated EMR system ensures physicians all along the continuum of care have access to the right data at the right time, reducing medical errors and improving outcomes.

The Institute of Medicine report “To Err is Human,” published in 1999, focused the nation’s attention on the risk of medical errors in healthcare delivery. At the time, it was estimated that medical errors were the eighth leading cause of death in the United States. Medical errors do not occur only in hospitals; they occur in ambulatory patient environments, particularly in the setting of patients transitioning from one care environment to another (for example, from home to the hospital, hospital to home).

In the ambulatory environment, there are millions of patient visits to specialists each year. The baby boomers are aging and there are a growing number of adults living with multiple medical conditions. As a result, both the number of referrals by primary care physicians (PCPs) to specialists and patient self-referrals to specialists are growing. In either case, such specialty visits may result in the patient’s care regimen being modified.

When the patient has the specialty consultation, if the specialist is unaware of vital patient information—such as the patient’s current medications, allergies, recent test results, and histories—and the patient inadvertently or purposely omits information, the specialist may prescribe care and medications that could result in an adverse event.

If, after the specialist reviews the new care plan with the patient, the patient returns home and is confused about his or her new treatment regimen (for example, whether it is okay to take the medication prescribed by the specialist as well as other medications prescribed by his or her PCP), the patient may take the wrong doses, take the wrong medications, or omit important medications—any of which could result in an adverse event. If the patient’s primary care doctor has not received information about the specialty consultation and is unaware of the changes to the patient’s treatment plan, then he or she may continue to prescribe what may now be obsolete or redundant medications and care processes, or start new medications that could interact with those prescribed by the specialist, resulting in adverse events.

Given these examples, it is clear that there is a critical need to ensure access to the flow of vital information to all of these constituents across transitions of care. A 2008 report from the Commonwealth Fund demonstrated that, during more than one-fifth of all patient encounters (22%), physicians had access to incomplete patient information.

EMRs promote communication between providers, but only if everyone has access to the system

Despite the availability of improved communications technology, lack of access and interoperability can still pose challenges to care coordination. All too often, physicians who have an EMR need to communicate with another physician involved in the patient’s care who either uses another brand of EMR or who doesn’t have an EMR at all. In this situation, the EMR user frequently resorts to what I call the “dump truck method” of communication: they gather together and print every detail about the patient from their EMR and send it to the next treating clinician. The receiving clinician, already overloaded with work and information, must then sort through this excess and decide which data is important enough to manually enter into their own records. This is clearly disruptive to their clinical workflow and creates the risk that the clinician or staff might inadvertently omit important information or make an error while transcribing the information into their system.

Physicians working in a large integrated delivery network (IDN), who refer their patients within the IDN and share an EMR system, have all of the electronic records at hand when a patient arrives for a visit. The primary care provider and specialist can readily communicate through the EMR and maintain an updated patient record. The existence of this readily available data that the system can read, understand, report on, and re-use allows for a variety of measures that can improve quality and reduce errors, including:

• EMR clinical decision support, such as medication-allergy and medication interaction, alerts visible to the clinician at the point of care
• Appropriate medication management through real-time, point-of-care medication reconciliation
• Prevention of duplicate testing
• Dramatically enhanced real-time clinician communication
• Graphically displayed results and trends
• Appropriate patient-centric disease management and health maintenance follow-up

Within an EMR-enabled IDN, these tools are available to the treating clinicians who share an EMR as part of their existing workflow. These doctors do not need to shuffle papers, log on to a separate electronic system, or enter data into their own records. All of the information they need is within their EMR exactly where they would expect to find it, regardless of whether the patient is referred by the patient’s PCP and being seen by the specialist, or is returning to the PCP after having seen the specialist.

Don’t think of it as more work

There is a tremendous effort currently underway to increase EMR adoption and “meaningful use” by all clinicians in the United States, many of whom are already overburdened with their workloads. For this effort to be successful, we cannot expect clinicians to disrupt their workflow and toggle across multiple systems as well as juggle paper. In order to support patient safety across these transitions of care environments, it will be critical to enable the flow of discrete data (date-, time-, and source-stamped) across all EMR systems regardless of the manufacturer of the system, so that clinicians can access important patient information when and where they need to, with no disruption to their usual workflow.

As EMRs and personal health records are more broadly adopted in the United States, it is essential that vital patient information flow across these systems so that treating physicians are immediately aware of changes made to a patient’s care plan, and the patient always has the most up-to-date information regarding his or her care plan readily available to avoid any confusion and assist in patient compliance. Succinct information about the care plan made accessible to providers as part of their normal workflow, and to patients in their chosen format (eg, the Internet, or on paper), will dramatically help prevent adverse events and improve the quality of care.

Care Transitions Resources

Coleman Care Transitions Intervention

Provides information about an intervention that “encourages patients to take a more active role in their health care” by providing them with “specific tools and skills that are reinforced by a ‘transition coach’ (a nurse, social worker, or trained volunteer) who follows patients across settings for the first four weeks after leaving the hospital.” The intervention includes several components, such as the use of a “patient-centered health record that helps guide patients through the care process.”

Project RED (Re-Engineered Discharge)

Project RED is a research group at Boston University Medical Center that “develops and tests strategies to improve the hospital discharge process in a way that promotes patient safety and reduces re-hospitalization rates.”

Care Transitions Program

Among the goals of the Care Transitions Program is to improve skills among healthcare providers, enhance the ability of health information technology to promote health information exchange across care settings, implement system level interventions to improve quality and safety, and develop performance measures and public reporting mechanisms.

Care Transitions Quality Improvement Organization Support Center

Go here to learn about programs and initiatives dedicated to “improving coordination across the continuum of care… and promote seamless transitions from the hospital to home, skilled nursing care, or home health care.”

Transitions of Care Consensus Policy Statement

This document identifies five principles for effective care transitions, focusing on accountability, clear and direct communication of treatment plans and follow-up expectations, the provision of timely feedback, involving the patient and family where appropriate, unless inappropriate, in all steps, and “respect of the hub of coordination of care.”

Holly Miller, MD, MBA FHIMSS, is Chief Medical Officer of MedAllies. She is a longtime member of the MDNG editorial board.