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THE EFFECTIVENESS OF AN HIT-BASED CARE TRANSITION INFORMATION TRANSFER SYSTEM TO

Award Number: R18HS017864
ORGANIZATION: AGENCY FOR HEALTH CARE RESEARCH AND QUALITY
OPDIV: AHRQ
AWARD CLASS: DISCRETIONARY
AWARD ACTIVITY TYPE: KDA (KNOWLEDGE/DEVELOPMENT/APPLICATION)
PERIOD OF PERFORMANCE START DATE: 09/30/2008
PERIOD OF PERFORMANCE END DATE: 09/29/2012

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THE EFFECTIVENESS OF AN HIT-BASED CARE TRANSITION INFORMATION TRANSFER SYSTEM TO - DESCRIPTION (provided by the applicant): Improved coordination of care across health care settings and enhanced health information technology have been identified by the IOM as two essential tools for improving health care management during care transitions. Yet, health care remains fragmented and poorly coordinated across treatment settings, often resulting in preventable medication errors, unnecessary hospitalizations and emergent care visits, avoidable adverse health events and dissatisfied patients and providers. Times of care transition can be particularly difficult for the medically complex patient, particularly in rural communities. The objective of this project is to improve the process by which crucial hospital discharge information is communicated to rural patients and their outpatient rural primary care providers. Specific aims include the development, implementation and evaluation of a care transition information transfer (CTIT) system. The system will rely on the current integrated electronic health record (EHR) in a large non-profit community health system and will include electronically generated: 1) comprehensive patient discharge instructions, including a patient-friendly medication list, provided to the patient at time of discharge and sent to the rural outpatient provider clinic; and 2) discharge information transmitted to rural outpatient providers regarding their high-risk patients. Rural providers will also be prompted to access more complete medical information by connecting directly to the hospital's EHR. Program evaluation will focus on specific clinical outcomes, such as patient adherence to medication instructions after discharge, patient receipt of reconciled medication lists, hospital readmission rates, and utilization of emergent care services; system efficiency outcomes, such as time to first patient ambulatory setting visit; and rural patient/family and inpatient/outpatient provider satisfaction. The research design is an 18-month prospective controlled intervention study, within a three-year project. Both prospective and retrospective data will be obtained from several sources, including data abstracted from a hospital EHR and manual review of rural clinic medical records; questionnaires administered to rural patients at time of hospital discharge or by phone interview; and rural patient and family satisfaction surveys. Study hypotheses posit that the CTIT system will be associated with improved patient clinical outcomes, system efficiency and process outcomes, and both rural patient and provider satisfaction with the care transition process. Success in achieving project aims may have a significant effect on patient care in rural areas by providing a health information technology (HIT)-based care transition information system model that could be easily disseminated to other health care systems. Positive results could significantly alter clinical practices surrounding the care transition process, which in turn may result in improved quality of care and patient safety. Use of existing HIT translates into a low cost system change that has the potential to greatly improve patient safety and quality of care for high-risk medically complex patients in particular, who are at the greatest risk for adverse events post-discharge.


Issue Date FY	Funding FY	Legal Entity Name	Legal Entity Address	Legal Entity City	Legal Entity State	Legal Entity Zip Code	Legal Entity COUNTY	Legal Entity COUNTRY	Assistance Listing	Award Code	Budget Year	Action Date	Action Type	Action Amount

Issue Date FY: 2012 ( Subtotal = $0 )
2012	2010	BILLINGS CLINIC FOUNDATION	POST OFFICE BOX 3566	BILLINGS	MT	59103	YELLOWSTONE	USA	Research on Healthcare Costs, Quality and Outcomes	000	3	11/21/2011	NON-COMPETING CONTINUATION	$0
														Subtotal = $0

Issue Date FY: 2010 ( Subtotal = $307,033 )
2010	2010	BILLINGS CLINIC FOUNDATION	POST OFFICE BOX 3566	BILLINGS	MT	59103	YELLOWSTONE	USA	Research on Healthcare Costs, Quality and Outcomes	000	3	9/15/2010	NON-COMPETING CONTINUATION	$307,033
														Subtotal = $307,033

Issue Date FY: 2009 ( Subtotal = $399,408 )
2009	2009	BILLINGS CLINIC FOUNDATION	POST OFFICE BOX 3566	BILLINGS	MT	59103	YELLOWSTONE	USA	Research on Healthcare Costs, Quality and Outcomes	000	2	9/8/2009	NON-COMPETING CONTINUATION	$399,408
														Subtotal = $399,408

Issue Date FY: 2008 ( Subtotal = $448,930 )
2008	2008	BILLINGS CLINIC FOUNDATION	POST OFFICE BOX 3566	BILLINGS	MT	59103	YELLOWSTONE	USA	Research on Healthcare Costs, Quality and Outcomes	000	1	9/18/2008	NEW	$448,930
														Subtotal = $448,930

Grand Total All Awards = $1,155,371

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THE EFFECTIVENESS OF AN HIT-BASED CARE TRANSITION INFORMATION TRANSFER SYSTEM TO

Award Number: R18HS017864

ORGANIZATION: AGENCY FOR HEALTH CARE RESEARCH AND QUALITY

OPDIV: AHRQ

AWARD CLASS: DISCRETIONARY

AWARD ACTIVITY TYPE: KDA (KNOWLEDGE/DEVELOPMENT/APPLICATION)

PERIOD OF PERFORMANCE START DATE: 09/30/2008

PERIOD OF PERFORMANCE END DATE: 09/29/2012

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