Development of Electronic Transition Tools for Home Health Care (continued, page 3)

Evaluation of Web-Based System (e-transitions) 

Development of e-transitions

Overview. The transition process, whether from home to hospital, hospital to nursing home, or even hospital to outpatient setting, is fraught with lost opportunities and poor communication. Multiple forms of communication are used, which can lead to confusion and unnecessary repetition of information flow. A Web-based system, such as e-transitions, creates a centralized electronic system, streamlining communication through E-mail. Information is sent and received in real time with verifications available to assure that the appropriate recipient has accessed any new information.

Diagram 1 represents the process of development of the Web-based system, e-transitions. Each shaded box is an entity sending and/or receiving clinical information via the e-transitions Web portal. Arrows to or from the e-transitions portal represent sending, entering, viewing, and/or editing data on the e-transitions Web site as well as E-mail notices to clinicians to check the Web site. The entities/users of the Web site are hospital-based and community physicians, visiting nurse, and patient; however, the patient function was not implemented for the study. The process can be summarized as follows:

  • Weill Cornell/NYPH (hospital based) physician overseeing care of patients in the study sends e-485 referral to home care and edits the patient's plan of care via Web site. Physician receives an E-mail indicating admission into home care or change to the current plan of care.
  • Community physicianc unaffiliated with Cornell overseeing care of patients in the study edits the patient's plan of care via the Web and sends e-485 by completing a home care referral form on the Web site. Physician receives an E-mail indicating admission into home care or change to the current plan of care.
  • Visiting nurse edits the patient's plan of care via the Web site and receives an email indicating an admission into home care or a change to the current plan of care.

The Web site was hosted by VNSNY and resided behind the VNSNY firewall. The communications protocol used to access the e-transitions Web site was secure http and the only way to get access to the site was to have a user ID and password granted to the user by the network security department of VNSNY. The E-mails sent to the nurses and physicians did not contain any patient-specific data and did not need to be encrypted; rather these E-mails were reminders to inform the clinician that data on a patient had changed.d

Programming and mapping to the Continuity of Care Record. A database was developed that includes the data elements in the e-485 and tracks the components of physician-nurse communication. To facilitate interoperability in the future, the e-485 was mapped to the Continuity of Care Record, a clinical summary document currently in development to improve the flow of information when a patient moves from one provider setting to another. (Appendix C illustrates the mapping of the e-485 to the Continuity of Care Record.) ASTM International (a large, voluntary standards development organization originally known as the American Society for Testing and Materials), the Massachusetts Medical Society, the Health Information Management and Systems Society, the American Academy of Family Physicians, and the American Academy of Pediatrics are jointly developing the specifications for the Continuity of Care Record. Standards currently are being developed for coding and messaging as well as for the content of mandated core elements and optional extensions.

Development of training materials. Instructional materials that included examples of how e-transitions could be used were created for physician users at New York Presbyterian Hospital and nurse users in the Central Admissions Unit and two VNSNY home care teams. (Appendix D presents sample screen shots from these materials.) Weill Cornell-NYPH and VNSNY clinicians participating in the pilot were trained in the functionalities of the Web-based system.

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Pilot and Focus Group Testing of e-transitions

Pilot testing. Two VNSNY adult care teams in Manhattan were identified as receiving by far the largest share of Weill Cornell-NYPH referrals. The Weill Cornell-NYPH physicians with the highest rate of referral to these teams were identified as the pool of physicians for possible participation in the pilot.

Appendix E presents the workflow diagrams that were created to clarify how the pilot test would affect day-to-day business operations at VNSNY. To increase the use of e-transitions over the 6-week pilot, all of the participating physicians' patients served by the identified adult care teams were included on the Web site. Research staff at VNSNY, with the help of team facilitators, manually input the most recent e-485 data for any patient currently in care a day before the pilot test began. Two nurse team facilitators and one team manager on the adult care teams participated in the pilot test. They updated information and initiated communication on e-transitions by reviewing interim orders and keeping in close contact with the home care nurses coordinating care in the patients' homes.

Six referring physicians and one nurse practitioner at Weill Cornell-NYPH were given access to their patients on e-transitions. As noted above, access was not granted to any patients since the patient home page on e-transitions was not linked to clinical information. Physicians were brought on to the system gradually to avoid overwhelming the VNSNY nurses with additional work. Research staff at both VNSNY and Weill Cornell-NYPH stayed in frequent contact with all piloting clinicians to address user questions and problems and to ensure that the pilot test ran smoothly.

Research staff tracked how often system users opened e-transitions and found that the e-transitions pages were accessed 1,300 times between October 23, 2006 and December 20, 2006 for 46 patients. Access to e-transitions was measured by counting the number of times Web pages with patient content were opened by a particular user. Referring physicians accessed patient information on e-transitions 565 times and VNSNY nurses accessed such information 735 times. As nurses are in more constant contact with home care patients, this would account for the larger number of changes and views of patient information initiated by the nurses.

Focus group testing. On completion of designing the Web-based tool, the e-transitions phase of this work was pilot-tested for 6 weeks with a selected team as described above. Subsequently, a focus group was conducted to elicit a general response and more specific feedback on the utility and feasibility of the e-transitions from a subset of users. All physician and nurse e-transitions users were invited to participate in the group. Information was collected from participants within three broad content areas:

  • User application interface—The process for gaining access to the secure Web site as well as the ease of completing and revising Web-based forms (such as the e-485).
  • Content and timeliness of messages—Availability of the right clinical information to the right person at the right time.
  • Communication and care practices of providers—Changes in communication and its impact on coordination of care and the adoption of evidence-based practices.

An invitation to the focus group was extended to all piloting users of e-transitions. Participation was voluntary and informed consent was obtained from each person. The following list of key questions was sent out a week prior to the focus group so participants could begin thinking about their responses and formulate additional questions:

  • What do you like/dislike most about the system in general?
  • How would you comment on the efficiency of e-transitions, including time saved and the avoidance of multiple rounds of faxes and phone calls?
  • What works and doesn't work in documentation?
  • Did you get information back in a timely fashion?
  • How helpful would you find guidelines around using phone vs. e-transitions?
  • What do you think is a reasonable frequency for checking e-transitions? Daily? Twice daily?
  • Should someone else, such as a nurse practitioner, screen E-mails?
  • If this is the standard means of communication, where should the message go?

Focus group participants included:

  • Two Weill Cornell-NYPH physicians and one Weill Cornell-NYPH nurse practitioner from the geriatrics practice who actively used e-transitions to make referrals to home health care agencies.
  • Two VNSNY nurses who actively used e-transitions (the team facilitator for each of the two participating teams).
  • One VNSNY nurse manager who received e-transitions referrals and used them to generate plans of care and who oversees one of the two piloting home care nurse teams at VNSNY.

User application interface. The overall response to the e-transitions pilot testing was positive and encouraging. Focus group participants discussed many of the positive aspects and the potential to lessen the paperwork burden and ease interdisciplinary communication, specifically citing the following attributes of e-transitions:

  • More timely capability to alert physicians when patients were being discharged from home care.
  • Increased capacity to facilitate non-urgent physician orders.

Although the participants were encouraging, they suggested the following needed improvements:

  • A more flexible format for the medication fields to allow for diversity of medication classes.
  • Further detail about appropriate time and method of use for communication (for example, e-transitions is currently inappropriate for urgent communication needs).
  • Verification that the communication has been received and read by the recipient.

Other points raised in the discussion included the following:

  • Incoming orders/notes must be monitored to assure they are addressed.
  • Orders/notes must be documented via e-transitions (for example, work after normal business hours) to assure nothing is lost or forgotten.
  • Gaps in care coordination, such as when the referring physician is not the physician of record, could be reduced if all physicians had access to e-transitions.

Content and timeliness of messages. Participants focused on the need to fit the system into their workflow and take advantage of E-mail, specifically:

  • All e-transitions users must incorporate at least daily checking of E-mail into their work routine. Currently clinicians generally only view the Web site when E-mail notifications arrive in their inbox; thus e-transitions does not fit in with current clinical workflow.
  • Clinicians' responsibilities and communication expectations (such as when to check E-mail) would need to be delineated prior to full adoption and integration of the system into practice.
  • Including the e-transitions Web site link in the E-mail verifications would expedite communication and make it easier to respond.
  • Even when E-mail is checked daily, users should log on to the Web site on a scheduled basis.
  • Screening of E-mails would facilitate physician notification when urgent attention is required.

Communication and care practices of providers. It was difficult to see any direct benefits or time saved over the course of the pilot because e-transitions was not included in day-to-day business operations. Although correspondence occurred via e-transitions, faxes still needed to be sent as part of standard practice. However, the group discussed potential benefits of the site related to communication and decrease of unnecessary faxes and other paperwork:

  • A system such as e-transitions would make it easier for a physician to access and track the most recent orders and assure they have been signed, thus potentially decreasing the number of recertification faxes received.
  • There is a need for clear, efficient communication and for everyone in the process to know who is responsible for care coordination. Keeping the home care nurse at the center is critical because they have the most complete picture of the full patient situation. A physician should not be able to change an e-485 until the nurse verifies what is going on in the home

In summary, both nurses and physicians viewed the e-transitions as a potentially efficient and effective means of communicating and collaborating about patient care. The main benefits of e-transitions cited by the focus group may be listed as follows:

  • As a Web-based system, e-transitions provides easier access to patient information.
  • The clear benefit of e-transitions is in its ability to facilitate requests for non-urgent clinical care.
  • The potential of e-transitions to decrease unnecessary phone calls and faxes (such as for recertification orders) is high.
  • Medications are very difficult as the site is currently formatted, and system improvements would likely benefit patients and professionals alike. The medication fields need to be more flexible and "user friendly."
  • Feedback loops are needed to alert senders that their orders and notes are read.
  • Provision of cross coverage for clinicians when they are away is necessary.
  • Professional expectations and responsibilities need to be clearly delineated (for example, frequency of E-mail checks, nurses' care coordination role).
  • The system will be most helpful and useful when integrated into clinicians' clinical practice and workflow.

Patient/caregiver interviews. After focus group testing was completed, phone interviews were conducted with one patient and five caregivers to collect information on VNSNY patient/caregiver use of computers for gathering health information and the type and format of information they want to effectively manage their health care. The six individuals were referred by physicians in the geriatrics practice at NYPH and recruited by staff at Weill Medical College.

Findings from the interviews may be summarized as follows:

  • Most respondents used the Web for health information but frequency of use varied widely.
  • Respondents who used the Web stated that they found information about doctors, doctors' backgrounds, medications, illnesses (including symptoms of illnesses and diagnoses), and both traditional and alterative (or nontraditional) treatments.
  • Most respondents who used the Web reported that they did not have problems locating health information on the Internet.
  • All of the Internet-users stated that the information they found was helpful; most indicated it was very helpful. Users specifically mentioned benefits such as being able to gather information to facilitate communication with their doctors about treatment options and to supplement what they received from their own physicians with additional information.
  • Respondents reported that if a Web site were set up to communicate information about home care, it should enable better communication between and with providers and augment the information they have about their health or that of the person for whom they provide care.
  • Respondents stated they would find the following types of information useful: alternative treatments, medications and side effects, and explanations of medical terminology.

Two major themes emerged from the interviews:

  1. A desire for more information.
  2. Improved communication with providers.

Even with the small sample, this finding is useful when considering how to implement technologies such as e-transitions. Specifically, most respondents currently use the Web to obtain information about physicians and/or general information about conditions and treatments. Some also want patient-specific communication with clinicians and information about individual patients.

Including links to trusted sources of information on clinicians and general information about conditions and treatments in Web-based systems such as e-transitions is one way to address the interest in using the Web for gathering information. Much more difficult, as noted above, is providing patient-specific information and communication due to privacy requirements and operational challenges (including issuing and tracking patient user IDs and passwords), as well as clinician concerns (and differences of opinion) about the extent to which medical information should be made available to patients and their caregivers.

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Conclusion and Lessons Learned

The e-485: Restructuring, Expansion, and Automation of CMS Form 485

Communication of timely, complete and accurate information between physicians and home agency personnel is essential for good patient outcomes.1-2,10 Technology can facilitate communication and improve patient care through the sharing of data.11 Nonetheless, availability is insufficient; there must be an incentive to use it. Traditionally, physicians and other primary care providers have not given high priority to working with home health agencies

In the hospital, a patient is admitted by a physician who performs an assessment, develops a plan of care, and writes a series of orders. Nurses, therapists and other professionals perform separate assessments, and together team members enact a plan of care. Communications may be imperfect, but they occur in real time; and the physician is not just involved but primarily responsible for the patient's progress. The return home of a hospitalized patient, on the other hand, is typically viewed as an end to an episode of care rather than as another admission requiring new diagnoses, goals, and orders.

The e-485, as described in this report, is intended to assist providers in standardizing the transition to promote a thorough, collaborative plan of care in the home. By itself, an electronic order set is an insufficient incentive to increase physician involvement in home care. Nonetheless, it has served as a facilitator and a teaching tool, and it could be part of a broader system that creates more intricate and functional ties between physician and home health agency.

Technology can maximize efficiency in communication so that systems run more smoothly. Other researchers have begun to explore the use of telehealth and telemonitoring technology to reduce overall health care utilization and physician office visits in the case of long-term disease management.2,11-12

It is challenging to introduce new technologies and systems in the complex health care arena. Clinical staff often feel overextended and in some cases overwhelmed by the pace of change and demands of care. Even modest changes such as those introduced in this project require a commitment to learning new procedures and a willingness to increase the clinical workload in the short run with the belief that more efficient and better care will result in the long run.

Although the e-485 continues to be used by the geriatrics and HIV clinics, to date it has not been actively used by the general internal medicine practice at Weill Cornell-NYPH, where home health care referrals are usually initiated by phone calls from nurses at the practice. Switching to an electronic referral system was met with some resistance. This is an important lesson in using electronic health records in complex practice settings: despite potential improvements in quality and communication, existing practice patterns can be difficult to change.

In addition, nurses do not have the authority to independently change medications in response to decision-support prompts. As a result, the overall referral to home health care may not be as complete or accurate when the nurse completes the referral in response to a physician order by relying solely on the patient's chart.

On the other hand, it is unclear whether it is useful enough to train physicians to complete a detailed e-485 if they rarely make referrals. Nurses who routinely work on hospital discharge plans and at the receiving agency are familiar with the process.They also may be in a better position to complete information on the care plan in the home as they have extensive knowledge of available services. Clearly it is better to have the involvement of a primary care physician, but at times the physician coordinator of care may be unavailable. Increased physician involvement in postacute care is the ideal, but it remains unclear as to whether and to what extent it is feasible in the e-transitions system.

Additional efforts are underway to increase the number of users at Weill Cornell-NYPH including its possible adaptation for use in the EPIC electronic health record (which is currently used across more than 150 users at Weill Cornell-NYPH). EPIC supports "smart" forms that can be programmed into the system, similar to the work done on the e-485 in the geriatrics clinical information system.

The e-485 is a first step in a complicated process to improve transitional care, combining technological advances such as electronic charting format changes that more clearly reflect medical decisionmaking. Because the transition process, whatever the venue, is susceptible to error, it is an essential area to target if patient outcomes are to be improved. Widespread adoption will occur at the time that new information technology (such as the e-485) is integrated into usual practice and within the huge and important process of creating compatible electronic systems of health care information management. In the case of the e-485, as with electronic health care systems in general, interoperability will be a critical undercurrent to efficiency, generalizability, and improved health care outcomes.

e-transitions: Creating a Web-Based Coordination and Communication System

The transition process is plagued with inefficiencies and poor communication. The current process of paper forms, faxes, and phone calls creates an environment that could easily put patients at greater risk for poor transitions. The purpose in designing e-transitions was to streamline the initial referral process, improve coordination of care, and provide enhanced communication. In addition, e-transitions was developed so that physicians and home health care agencies without electronic systems could use the Internet to get access to enhanced information based on the e-485. The system also included interpretability standards that existed at the time of development so that other hospital electronic health records could be programmed to extract data from their systems and sent to e-transitions at the time of referral. These data would then be readily available to providers as patients' transition from the hospital to home health care.

Although e-transitions was only "live" for 6 weeks and included a limited number of actual patients, positive feedback from the providers suggested that e-transitions could be a powerful transitional tool. With further development, e-transitions could eventually become a resource for other providers and organizations to improve the transition of patients across settings. It could also be expanded to include skilled nursing homes and rehabilitation settings. A Web-based application such as e-transitions potentially could provide home health care agencies and skilled nursing homes with access to a very low-cost mechanism to improve transitions.


c The complexity of pilot testing involving Weill Cornell/NYPH physicians precluded participation of community physicians in the pilot test.
d The patient function was not implemented because of unresolved issues surrounding the type of patient information that would be available and the mechanics of granting user access in accord with confidentiality requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA)


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Current as of September 2007
Internet Citation: Development of Electronic Transition Tools for Home Health Care (continued, page 3). September 2007. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/hcbs/etransitions/etransitions2.html