Document Type


Degree Name



Dept. of Medical Informatics and Clinical Epidemiology.


Oregon Health & Science University


Research in transitions of care has shown that information flow from hospitals including notification of admission, discharge summaries and medication lists is often poor and undermines good transition handoffs. In spite of efforts to create interoperability and communicate important information about transitions of care, the flow of information is inconsistent, not supported by electronic health record (EHR) functionality, dependent on workarounds within the primary care provider (PCP) practice, and has little feedback to promote quality improvement efforts. EHRs typically do not have tools to track patients who are outside the office, in the hospital, emergency room, subacute or skilled nursing facility. Practices trying to follow and manage these patients often create their own workarounds such as spreadsheet tracking lists. These lists are primarily used for tracking discharges, so that patients can be contacted to perform medication reconciliation and schedule a follow up office visit. These lists are created from a variety of sources including Notifications of Admission (NOA), hospital records such as admission history and physicals, discharge summaries, notification from hospitalists, census data retrieved from a hospital portal, or often just from scattered reports such as consults, that the practice receives. A potential solution would be a web based application to assist primary care practices in tracking their patients across transitions of care, tracking the data associated with those patients such as notifications of admission (NOA), admission histories and physicals (H&Ps) and discharge summaries, and providing tools to follow those patients and better manage those transitions. This tool and process should allow physicians to better identify their hospitalized patients, manage their transitions and reduce readmissions. Better identification of admissions and discharge may also allow better capture of reimbursement for transitions of care management. Hospitals would benefit if the application helped to reduce readmission rates and the cost of care related to avoidable post discharge events. The data collected can also be used to assess communication around transitions of care and provide feedback to hospitals and the local Health Information Exchange. The question for this study is if a web based transitions of care application would be more effective, efficient, and desirable than current methods in identifying and managing transitions of care, and which features would be desirable. The proposed application would aggregate information from the Health Information Exchange and present to the primary care provider in a way that would align with their workflow. Primary care providers, hospitalists, hospital information officers and thought leaders in this area were surveyed and interviewed to build an understanding of the desired functionality of such an application. Identification of the primary care provider at the time of hospitalization was identified as a critical gap in improving the flow of transitions of care information.




School of Medicine



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