Mitigating Error Vulnerability at the Transition of Care through the Use of Health IT Applications
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- Cortelyou-Ward, K., Swain, A. & Yeung, T. J Med Syst (2012) 36: 3825. doi:10.1007/s10916-012-9855-x
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Adverse drug events are largely considered to be errors in which the severity of effects could be lessened or even prevented through more effective medication reconciliation practices. Transitions of care, particularly at the time of discharge from the hospital, represent a time of heightened error vulnerability that contributes to medication discrepancy occurrences. The observed vulnerability can be attributed to communication and care continuity gaps across health care settings and can often lead to preventable errors. Health IT tools developed through research can identify factors which increase the risk of medication discrepancies. Additionally, the implementations of optimized clinical workflow processes to form effective transitions of care are approaches to decreasing medication discrepancies which may lead to adverse drug events. While federal policies and certifying organizations have implemented quality initiatives to increase focus on medication reconciliation practices in the hospital and primary care settings, the same practices must be implemented after a patient is discharged to their homes or another health care facility in order to mitigate error vulnerabilities that occur at the transition of care. This paper provides an overview of health IT system capabilities and their applications within and across health care delivery settings to facilitate care coordination to ensure continuity of care.
KeywordsTransition of careHealth information technologyAdverse drug events
Inherent error vulnerability at the transition of care
It has been estimated that more than 40 % of adverse events that occur in a hospital setting are related to medication errors. Moreover, medication errors are most common at the transition of care, which includes admission, transferring and discharging of patients . A way to mitigate adverse drug events (ADEs) at the transition of care is to implement a process known as medication reconciliation. A study conducted by Vira et al. , supports the use of medication reconciliation as a method to identifying and reducing medication errors during the patient’s transitioning of care.
The process of medication reconciliation involves obtaining the most complete and accurate list of medications the patient is currently taking and comparing it to the patient’s new medication order . This process needs to occur at every interface of care to reduce the likelihood of medication error. If medication variances are detected, it is crucial to investigate and rectify the errors before a patient is put at risk. Research on the effectiveness of medication reconciliation is limited; however, one study found that medication reconciliation led to a 76 % reduction in medication errors .
During the hospital discharge process, the patient comes in contact with several members of the hospital staff and is inundated with education and instructions for their post-hospital care. This drastic change from complete care by hospital staff to individual or assisted care at home or at another health care facility contributes to confusion and the inability to identify factors that may hinder the patient’s recovery. Examples of such occurrences include forgetting to continue new medication regimens or confusing new dosage schedules changed by the inpatient physician during treatment at the hospital . In cases where patients transfer from the hospital to another health care facility, such as skilled nursing facilities, the transition presents a time of increased potential for error due to lack of oversight by hospital staff and clinicians and resulting increase in lack of accountability . With many processes occurring at discharge, overwhelmed and rushed clinicians may forget to update medications completely or neglect to reconcile new or changed medications with pre-admission regimens . According to the Coleman et al.  study, medication discrepancies at the time of discharge are due to incomplete or illegible discharge instructions, conflicting information, unnoticed medication allergies, and/or duplication. These factors outlined in the Coleman et al.  study are often the result of multiple unaffiliated provider oversight of a single patient during their hospital stay and culminating with typically complicated and rushed discharge process.
The Coleman et al.  study also identified other common factors occurring at the transition of care contributing to medication discrepancies. Not surprisingly, patients prescribed a higher number of medications experienced a higher percentage of medication discrepancies. During a care transition, decreased health professional oversight and support leads to formulary-driven medication substitutions across settings .
Additionally, the period of transition between health care settings strains communications. Studies have demonstrated that some physicians cannot effectively communicate discharge instructions to their patients. Examples of this may include speaking to the patient assuming knowledge of complex medical concepts, providing a great amount of information and/or instruction, or the failure to provide visual aid material to aid a patient’s comprehension of discharge instructions . In order for patients or caretakers to provide adequate and appropriate care post-hospital discharge, it is important for doctors and/or nurses to effectively communicate to the patient or their caretaker(s). Gaps in communication and coordination increase error vulnerability during the transition of care and efforts to increase quality of care and patient safety must focus on eliminating internal care team communication and patient instruction communication gaps.
Prevalence and key indicators of ADEs upon transfer from hospitals to SNFs
With increased error vulnerability at the transition of care due to communication gaps, rushed clinicians, and decreased oversight and accountability, the elderly population faces an increased risk for errors with typically higher amounts of prescribed medications, dependence on family or other health care professional care, and limitations on receptivity to instruction or education. Studies analyzing prevalence and key indicators of adverse drug events (ADEs) offer insight to quality initiatives and the importance of their application to the vulnerable elderly population.
ADEs are a result of medication variances or discrepancies mostly at the transition of care. This is further exacerbated, as the elderly population is more likely to be transferred from one health care facility to another . It has been estimated that 20 % of patients experience ADEs between the transitions of care from hospital to a skilled nursing facility . Additionally, the following characteristics of patients are at an increased risk for re-hospitalization within a 90-day interval and they include individuals over the age of 80, “discharged within the previous 30 days,” suffering from 3 or more comorbidities, using over five or more prescription medications, “difficulty with at least 1 activity of daily living (ADL) and inadequate discharge instructions” .
In the Tjia et al.  study of hospital to skilled nursing facility (SNF) medication discrepancies, 50 % of discharge summaries did not match patient referral forms used in SNF admissions. Furthermore, the Tjia et al.  study estimated 3.5 medication discrepancies per patient admission that aligns with comparable studies estimating a range of 40–70 % medication discrepancies in the discharge summaries. The majority of medication discrepancies revealed in the study were prescriptions to be taken on a scheduled basis, indicating dictation or transcription errors and inpatient clinical workflow flaws .
Studies examining patient transfers from hospital discharge to SNF including Boockvar et al. , Boockvar et al. , Coleman et al. , and Tjia et al. , all identified cardiovascular agents, anticoagulants, and opioid analgesics as posing the highest risk for medication discrepancy-related adverse drug events and rehospitalization within a 30-day period. The Coleman et al.  study asserts the observed higher prevalence of discrepancies for patients with congestive heart failure indicates a higher frequency of medication regimen changes and the evidence-based recommended treatment regimens prescribing multiple different medications are well developed (p. 1845).
Use of health IT systems to mitigate transition of care error vulnerabilities
Health IT systems and effectiveness
Clinical Decision Support System (CDSS)
Supplement care planning through performing checks in real time, assisting with calculations, and alerting care providers of potential adverse events based on the patient information contained within the system .
The effectiveness of CDSS on patient outcomes holds promise, but further research is needed to draw significant conclusions 
Computerized Physician Order Entry (CPOE)
CPOE systems enable patient-centered recommendations for treatment decisions based on evidence-based clinical guidelines and the patient’s medical history based on data captured within the EHR-S.
Used with CDSS, CPOE has been shown to reduce medication errors 
Electronic Prescribing (E-Prescribing)
E-prescribing systems streamline prescription orders through a single portal forcing clinicians to enter medication information in a legible, defined format.
Used with CDSS and CPOE, E-prescribing holds the best hope for reducing medication errors. However, great caution should be exercised when using this system as medications may not be accurate or up to date.
Electronic Health Record System (EHR-S)
EHR-S take on an active role in patient care through utilizing data stored within the patient’s health record to facilitate care planning.
EHR-S alone do not provide adequate support for the reduction of medication errors.
CDSS supplement care planning through performing checks in real time, assisting with calculations, and alerting care providers of potential adverse events based on the patient information contained within the system . The system serves as an active support for physicians through providing relevant, functional feedback for patient care decisions from multiple knowledge bases. Furthermore, CDSS provide reminders to clinicians to perform preventive health tasks . The Garg, et al.  study on effectiveness of CDSS utilizing clinical trials in varied health care settings confirmed an improvement to practitioner performance based on 100 studies. In one portion of the Garg et al.  evaluations on reminder systems revealed 76 % of the CDSS were beneficial to practitioner performance. The authors concede the effect on patient outcomes remains inconsistent and cite a need for more studies to effectively demonstrate the CDSS benefits to patient outcomes.
To facilitate orders, CPOE systems provide a single location for order entry. The CPOE systems enable immediate confirmation of order placement and allow for review at the point of care. When used in conjunction with a CDSS, CPOE systems enable patient-centered recommendations for treatment decisions based on evidence-based clinical guidelines and the patient’s medical history based on data captured within the EHR-S. The Agrawal  review of information system use to reduce medication errors highlights a reported 55–83 % reduction in medication errors due to CPOE including decision support. The Agrawal  study confirms the Institute of Medicine Committee on Identifying and Preventing Medication Errors (2006) report detailing medication error rates and suggestion for the use of CPOE systems due to an estimated reduction of medication errors by 80 %.
Electronic Prescribing (e-prescribing), as part of the CPOE with CDSS, offers an efficient solution for facilitating prescription orders where the paper-based process often leads to errors resulting from illegible handwriting, incorrect dosing, and/or missed drug-to-drug interactions and drug allergies. E-prescribing systems acting independent of decision support systems maintain the benefits of streamlining prescription orders through a single portal forcing clinicians to enter medication information in a legible, defined format, but when used in conjunction with a CPOE with decision support, the system reduces the potential for medication errors through alerts for reconciling and updating patient medication information .
It is imperative to note patient-centered alerts can only be generated based upon accurate and up-to-date information contained within the systems. Medications prescribed by clinicians at other health care facilities and not included in the patient’s electronic file remain a potential risk for ADEs because the system will not detect potential drug-drug interactions or drug allergies . As health IT system adoption increases and health information exchange practices are defined, inclusion of all clinical information for a patient enables greater accuracy in diagnoses and treatment while decreasing potential errors which may have not been included in a single health care facility’s EHR-S.
Application of ‘meaningful use’ beyond the primary and acute care setting
Studies examining ADEs in relation to medication discrepancies have confirmed the need for more thorough and effective medication reconciliation practices. Several Quality and Safety Organizations, including The Joint Commission and The Society of Hospital Medicine, have instituted medication reconciliation requirements as part of patient safety and quality of care initiatives to improve the transition of care process. More recently, the federal regulations requiring the ‘Meaningful Use’ of EHR-S set measures and objectives for eligible providers and eligible hospitals for an incentive which focus on effective transitions of care practices including medication reconciliation, updating patient allergy information, and issuance of summary of care upon transferring health care settings, confirm the necessary improvements recognized to improve patient safety .
While many health care facilities are currently building health information exchange networks or have implemented interfaces to exchange information electronically with specific systems, entities lacking electronic health information systems may still be sent patient information that is printed, emailed, or faxed to ensure complete and effective communication across health care settings. As ‘Meaningful Use’ stages are defined, an increased focus is on the ability to exchange health information across health care settings to enable improved coordination of care. Care transitions require coordination between health care delivery settings, including a patient’s home, to ensure continuity of care. Health information exchange allows for pertinent patient health information to inform health care delivery practitioners and decrease potential errors which are largely preventable and unnecessarily contribute to health care costs. Health IT systems are tools that have been recognized to prevent medication errors and provide solutions to communication and accountability gaps.
Studies have highlighted factors which provide further insight into areas where health IT systems provide the necessary tools to assist in clinical decision making and diminish medication discrepancies. The Boockvar et al.  study asserts, “tools could be designed to identify high-risk medication discrepancies, identify patients at higher risk of ADE and alert providers taking care of patients who are transferred between sites of care” (p. 35). Tools supplementing current health IT systems developed through evidence-based research studies will facilitate quality of care improvement strategies and increase patient safety.
With greater health IT system adoption due to certification body regulations and government policies, more research may be conducted to support practices to realize the full benefits. Evidence supporting health IT adoption and their impact on clinical outcomes has drawn skepticism due to potential benefit calculations relying on best-case scenarios . As adoption of health IT systems increases and encompasses diverse types of health care settings, further evidence will enable successful and effective health IT system implementations and use that optimize clinical workflow processes to realize improved coordination of care.
As part of the American Recovery and Reinvestment Act (ARRA) of 2009, the Health Information Technology for Economic and Clinical Health (HITECH) Act was enacted to support the adoption and implementation of health IT systems to improve quality of care and care coordination, ensure patient safety, and decrease health care costs. The primary component of this legislation is the Centers for Medicare and Medicaid (CMS) Meaningful Use policy guiding “eligible professionals” to adopt, implement, and utilize EHR-S in a meaningful manner which promotes quality of care at the ambulatory point of care. While the Centers for Medicare and Medicaid (CMS) definition of an “eligible provider” for incentives do not encompass post-acute care providers such as SNF clinicians, measures dictating interoperability specifications for the exchange of electronic health information set the groundwork for a health IT infrastructure enabling the exchange of health information among all clinicians.
In 2010, the Patient Protection and Affordable Care Act (ACA) brought health care reform to the forefront of national priorities and expanded on the initial health IT groundwork HITECH had positioned to address care coordination gaps through inclusion of entities beyond the primary care physician and acute care hospital. As a key piece in enabling better care coordination, provisions specific to the transition process ensures continuity and quality of care across the health care delivery spectrum. These provisions include grant programs for the adoption and use of certified EHRs by post-acute care facilities, participation of post-acute care facilities in state health information exchange (HIE) programs, and implementation of content and messaging standards for the exchange of clinical data by long-term and post-acute care facilities.
The ACA, HITECH, and Quality and Safety Organization provisions use health IT system capabilities to outline best practices to improve care coordination to ensure patient safety. While effective use of health IT systems within a health care setting is an important step in realizing better quality of care, expanding these practices beyond the primary and acute care setting increases the opportunity to detect potential adverse events through access to current, accurate, and complete patient health information.
Physician and consumer buy-in of health care information technology
Research and studies have proven that in order to mitigate medication errors, which account for a large proportion of adverse medical events, hospitals need to implement and enforce medication reconciliation processes . Workflow problems have been cited as a deterrent to the adoption of health IT systems . Although studies have proven the effectiveness and cost-efficiencies of implementing IT systems, it does not come without drawbacks. Implementing new health IT systems will bring about unanticipated errors. Additionally, if the system is not optimally integrated within the workflow of the organization, it can generate extra work for clinicians . A second barrier to the adoption of health IT is the heavy capital investment required for implementation and maintenance. Furthermore, failure to demonstrate the benefits of health IT systems to clinician users threatens adoption rate .
The support and buy-in of physician and consumer is imperative to health IT overcoming implementation barriers and drive adoption success. The first step is to establish buy-in of the physicians and clinicians who will use these technologies. The usability factor plays a commanding role in attracting physicians and clinicians to effectively use health IT systems. According to the Health Information and Management Systems Society , a useable system needs to encompass three attributes: effective, efficient and satisfactory. An efficient system will decrease the time it takes health care staff to perform a task. An effective health IT system possesses the ability to enhance care delivery and actively prevent medical errors. Satisfaction of health IT systems will increase if they are capable of supplementing traditional care delivery and improve the clinician’s ability to make effective care decisions .
Demonstration of the value of health IT systems to the patients is crucial to developing a health care conscious culture. Physician support for health IT systems will perpetuate patient engagement and consumer buy-in. Furthermore, ensuring the buy-in of patients requires actively engaging the patient in their health and health planning. Personal health IT systems will enable fast and convenient access to medical information and will promote patient ownership of their health.
Mobile devices have the ability to give patients easy access to their personal health information . Mobile devices are effective tools to engage the patient beyond the traditional heath care setting and provide the means to actively track and monitor patient health information. Additionally, mobile devices offer a means for patients to engage in disease management and preventive medicine . The capability to generate medication alerts or appointment reminders further provides convenient and relevant health information to engage the patient. The ability to manage and retrieve patient medical information on a convenient and familiar device offers a “low hanging fruit” to promoting patient engagement and allows for the patient to take an active role in their health care planning . This capability will prove especially important during the transition of care through active patient participation. Although the elderly population may not possess the proficiency to operate mobile health technology, the burden to caretakers may be decreased through the use of health care applications on mobile devices.
Through the use of health IT systems, the mitigation of error vulnerability at the transition of care will be increased. Organizations utilizing medication reconciliation practices have a great interest in promoting patient engagement with the prospect of cost savings resulting from a decrease in expenditures typically stemming from medication errors. Effective medication discrepancy prevention occurs through the active involvement of all care team members and the patient or caregivers. Responsibility must fall on the patient to communicate and engage in their health care needs.
Integration of health IT systems to prevent medication discrepancies
With health IT systems improving as a result of wider adoption due to policy provisions and quality initiatives, the effective use by physicians and eventually, the patient, is imperative to the realization of increased patient safety and quality of care. At the heart of these goals is coordination of care enabled through more effective communication and greater access to accurate and current patient health information. While health IT systems are built to support current clinician workflows, their implementation and effective use requires inevitable changes to existing workflows. These changes are often perceived by clinicians to be obtrusive as they may require extra steps for carrying out processes that may not have been previously required. Examples include the clinician performed a task at a different point in their workflow or may not have personally performed a task now required as part of the health IT system. Individual organizations have adopted practices to appease these obstructions through the use of mobile devices, computers-on-wheels, and speech-to-text software. More effective practices include reorganizing work areas to accommodate the modified workflow or remodeling work areas to truly integrate the health IT infrastructure. Through more effective integration of the health IT system into the clinician workflow, benefits of system use will be realized.
In addition to structural workflow changes, clinician-patient interactions must also adjust in order to maximize health IT system value. While the structural workflow changes seek to increase ease of access to the systems, the clinician must adjust how they enter information and order in which they enter information to ensure the health IT system contains the most current and accurate patient health information. Health IT systems may only perform tasks based on data entered in the system. For tasks such as medication reconciliation, alerts are only generated based on the data in the system. In the event of a clinician failing to perform this task, a potential alert may not generate when a new order is placed for a duplicate medication or a medication that may be harmful to the patient.
As the health care system evolves to include wider adoption of health IT systems beyond the primary and acute care settings, patient-engagement will remain key to achieving overall health care priorities. It is crucial for the patient to take an active role in their health and to be involved in health care decisions. As patients become accustomed to interactions with EHR-S in care settings, awareness of processes will enable participation in health care decisions. An example of such participation would be a patient requesting a verbal list of current medications provided by the clinician so that they may voice concerns or provide additional information. Beyond the traditional health care setting and health IT systems, personal health records (PHR) and mobile health IT applications provide alternative solutions for health education and preventive medicine practices to engage the patient. These patient-centered health IT systems provide a convenient and manageable supplement to physician care.
Health IT systems are ultimately a tool to be used to facilitate and supplement health care delivery. As adoption of health IT systems increase within the primary and acute care setting and health information exchange extends to long-term care facilities, post-acute care facilities, a patient’s home, and mobile devices, health IT systems enable closing the loop on health care coordination and delivery. The health IT ecosystem allows the patient to take an active role in their health care decisions and to potentially mitigate and even prevent adverse events and medication discrepancies.
Efforts to increase relevance of health IT to the LTPAC community
As national priorities increase their focus on the long-term and post-acute care (LTPAC) community and their integral role in advancing health care improvement initiatives, opportunities to expand adoption of LTPAC–specific EHRs capable of exchanging health information with HIEs are growing and harmonization efforts are being piloted. In 2005, American Health Information Management Association (AHIMA) formed the LTPAC HIT Collaborative to advance health IT efforts in the LTPAC community . The Assistant Secretary for Planning and Evaluation (ASPE) supported the Collaborative efforts to align MDS 3.0, the electronic version of the CMS 485 form, and OASIS-C standards with national health IT content standards to attain interoperability. Their work is centered around linking the currently used MDS 3.0 and OASIS-C assessment tool data elements to industry content standards such as LOINC, ICD-9 and SNOMED-CT, mapping to the HITSP C32 CCD and HITSP C83 content modules, and aligning with the HITSP C154 data dictionary.
Pilot programs funded through federal grants have built on this work to increase interoperability through building upon commonly accepted health IT exchange practices. In 2011, the ONC issued “Challenge Grants” to four states’ HIE programs in support of improving LTPAC transitions. One recipient of the grant is the Massachusetts IMPACT program that is working to extend the HL7 Continuity of Care Document (CCD) to include data elements from a Universal Transfer Form (UTF) to support decision-making and information sharing at the point of transfer to reduce unnecessary hospitalizations and readmissions . Another ONC grant type promoting health information exchange initiatives, Beacon Community Programs, supports the Keystone HIE (KeyHIE) in efforts to engage nursing home and home health care agencies. The KeyHIE initiative is building an exchange system to accept all MDS 3.0 and OASIS-C submissions and exchanging them with CMS in a standards-based, interoperable format . Another important effort is the New York e-Health Collaborative and Visiting Nurse Services of New York (VNSNY) program creating an interoperable plan of care to be consistently updated and shared between providers and home care agencies .
All of these efforts and increase in federal funding opportunities reflect the national spotlight on the need for relevant and functional health IT applications for long-term and post-acute care providers. Through adapting currently used processes and standards, health IT may build upon and add value to the transition of care process to mitigate error vulnerability.
While care transition processes have inherent factors increasing the risk for errors and medication discrepancies resulting in ADEs, health IT systems provide tools to improve the process and decrease the prevalence of ADEs. Health information technology including electronic health records, CPOE, CDSS and e-prescribing are some of the many technological tools that has the capability to decrease adverse events in the health care setting. Mobile devices are emerging as a convenient and accessible tool to engage patients in their own health. With support from both physicians and patients, health care information technology has proven to decrease medical errors. Most importantly, these tools can close communication and care continuity gaps and promote more effective care transitions to reduce preventable and unnecessary errors which increase health care costs.
More research on the especially vulnerable elderly patient population will identify factors that can be used to develop specific health IT tools to reduce the severity of or prevent ADEs. A focus on increasing the effective utilization of health IT systems relevant to the long-term and post-acute care community is essential to the assurance of patient safety beyond the hospital setting. The ‘meaningful use’ of health IT systems by health care facilities beyond the hospital and primary care settings enables more effective transitions of care which is essential in order to improve quality of care and patient safety.
Conflict of interest
The authors declare that they have no conflict of interest.