: Poorly executed care transitions as patients move from one delivery setting to another lead to fragmented care evidenced by duplication of services, inappropriate and conflicting recommendations, medication errors, and patient confusion and distress. The lack of timely transfer of essential clinical information is a major barrier to effective care transitions. ? Three large Minnesota-based health care delivery systems have come together to use information technology to enhance communication at care transitions of patients with congestive heart failure and to evaluate its impact. The long-term objective which is crucial to the well being of the 100 million Americans with chronic illness and a rapidly growing population of elderly is to enable more informed clinical decisions which should result in safer and higher quality care of patients undergoing transitions. In addition, information exchange will be employed to facilitate the development of complete medication lists to be used as part of each organization's medication reconciliation process. The partners will execute an implementation plan for a community-shared electronic medical record abstract designed to enhance the care and safety of those crossing delivery sites. This abstract will be available near the point of care. Using a federated information model, the abstract will be a composite derived from the electronic medical records of each partner. The abstract will hold pertinent information such as a problem list, medications, allergies, recent procedures, and baseline physical, physiologic, and cognitive function supplemented by recent prescription claims history.
The specific aims are to successfully execute the implementation plan, to evaluate the effect the shared abstract has on the care of patients with CHF by measuring indicators prior to the intervention and during both of a two-phased intervention using health information exchange, and to demonstrate the integration of other clinical users into this information exchange once the project is operational and has documented its connection and participation standards. ? ?
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