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Putting the IT in TransITions December 5, 2011 Briefing On Friday, October 14, the Office of the National Coordinator for Health

Information Technology (ONC) participated in “Putting the IT in TransITions,” a convening hosted by the John A. Hartford Foundation, the Gordon and Betty Moore Foundation, and Kaiser Permanente. The Partnership for Patients, Health Affairs, and Health 2.0 were key participants among other widely known individuals working to improve the safety of patients as they transition between settings of care. The urgency for the convening stemmed from a shared belief around the need for a technology agenda to improve care transitions: While technology is not the primary driver for improvement of care transitions, usable and timely information flow and feedback is critical to achieving high quality, seamless transitions. Additionally, technology-enablement has the potential to support more rapid and affordable scaling of promising interventions. The intractable challenges faced by individuals during transitions (e.g. patients, care givers etc) should drive prioritization of the technology agenda Nearly 200 clinicians, technology leaders, policy leaders and vendors/innovators joined in the discussion at the Kaiser Center for Total Health including representatives from several Beacon Communities with care transitions interventions. Over 600 individuals requested invitations to join by webcast, with 95 tuned in at any one time. The archived webcast and supporting materials will be available through January 1, 2012 (click here). Brian Ahier (@ahier) Burwell Photography coordinated a social media strategy that included a vibrant twitter discussion with over 75 participants and over 750 tweets (#ITrans) reaching over 30,000 twitter users. A summary of their discussion can be found here. Through a combination of calls to action by Federal leaders Farzad Mostashari and Todd Park, break-out sessions, conversations with diverse stakeholders and a group prioritization activity, attendees prioritized the role of health IT in improving transitional care interventions, identified areas for near term improvement and opportunities for innovation. Todd Park, Chief Technology Officer at HHS and Farzad Mostashari, National Coordinator for Health IT framed the day with some energized words. Todd Park said, “The biggest barrier to healthcare changing is believing that it actually can…” Mostashari, optimistic, said, “underpinning, supporting, enabling, catalyzing each of those three: how patients are cared for, how care is paid for, and how people take care of themselves is the simple concept that information is power.” [Type text]

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"The biggest barrier to healthcare changing is believing that it actually can…” – Todd Park

Putting the IT in TransITions December 5, 2011 Briefing The convening also included opening remarks from Donna Cryer who introduced the group concrete opportunities for improvement based on more than 15 transitions as a patient, and twice as a caregiver to a spouse and a patient. Joanne Lynn, MD, Altarum Institute and national expert in care transitions said “We spend a fortune treating people and then send them on with a kiss and a kick. There is a light on the horizon. So many people are saying enough is enough. Change will happen.” The convening agenda was designed to discuss opportunities and challenges related to hospital discharges, readmission occurrences, and the IT interventions that can improve these transitions for patients, families, and medical professionals. Following these calls to action, attendees divided into break-out sessions where they:
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"Underpinning, supporting, enabling, and catalyzing each of those three: how patients are cared for, how care is paid for, and how people take care of themselves is the simple concept that information is power.”– Farzad Mostashari

1. Identified promising transitional care models and approaches that work, and uncovered where the biggest gaps or problems remain; 2. Prioritized opportunities for innovation that can improve transitions of care, with a particular focus on health IT innovation; 3. Pledged to engage in specific actions that can be taken in their local communities and engaged other meeting participants and others in their communities to foster greater innovation/development in this area. Convening participants attended 1 of 5 sessions to gain clarity on the most important problems, and the opportunities for improvement and innovation. 1. Discharge planning 2. Medicine Reconciliation 3. Information flow and feedback (2 sessions) 4. Patient and care giver engagement Mid-way through the day, in-person and virtual attendees heard recommendations and findings from each break-out session, and ranked their top topics and challenges to add to the “IT/Transitions” agenda in a real time prioritization exercise. Dr. Eric Coleman offered framing remarks to introduce the prioritization exercise and encouraged participants to be mindful of how technology supports patients: “Care transition plans with HIT need to be reality tested with patients and caregivers.”

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During lunch, senior leaders from the host organizations and media partners joined Farzad Mostashari for roundtable discussions about “what we are learning” and “where we are going.”

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Putting the IT in TransITions December 5, 2011 Briefing

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They provided some memorable and important statements:
“The system is complacent, we have tolerated this way too long. Taxpayers, caregivers, providers, and everyone who plans to age (i.e., everyone) have a vested interested in improving the current system.” - Chris Langston, PhD, Program Director at the John A. Hartford Foundation “Now is the time for action. We need smart people to find amazing actions that we can take.” - George BoLinn, MD, Chief Program Officer at the Gordon and Betty Moore Foundation “Transitions are ubiquitous throughout healthcare; some we do well and others we have an opportunity to improve.” - Scott Young, MD, Associate Executive Director of Clinical Care and Innovation at Kaiser Permanente “Keeping patients from getting injured or sicker can save thousands of lives and has the potential to save up to $35 billion across the health care system, including up to $10 billion in Medicare savings, over the next three years” - Paul McGann, Co-Director at HHS Partnership for Patients “Health Affairs is looking towards the future by chronicling innovation as it happens. We want great innovation stories on IT work in healthcare to feature in our series of ‘Innovation Profiles’.” - Susan Dentzer, Editor-in-Chief, Health Affairs. “The best thing is to talk about what you are doing to people in other industries and fields, audiences other than the ones you might normally engage.” - J.L. Neptune, Senior Vice President at Health 2.0.

Doug Fridsma, the ONC Director of Standards and Interoperability (S&I), Jitin Asnaani, Coordinator of the S&I Framework and Holly Miller, CMO of MedAllies, shared progress and a vision for how standards can better support transitions of care, and offered guidance for communities and organizations who wanted to join the open community. Areas of Convergence: Results from the group prioritization activity Burwell Photography After reviewing the discussion group details, and the survey results, 4 topics were repeatedly punctuated by meeting participants as requiring attention on our shared agenda: 1. Shared care plan development and visibility 2. Variability in care settings and care providers 3. Feedback loops 4. Medication reconciliation

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Putting the IT in TransITions December 5, 2011 Briefing

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Summary Table: Group Prioritization Activity (Language Slightly Modified) Question Top Responses (% of Responses) Of the priority problem statements that There is no care plan that includes my medical and social factors, coordinates interdisciplinary emerged from the break out sessions, the input (including my input), process and milestones, and that’s reconciled across time and setting three most important are: (56.4%) The care providers who have the most insight to help with the transitions have no ability to inform/see the plan, e.g., PCP, public health department, family, home health, SNFs, pharmacy etc. (51.5%) “It’s about me” across the continuum, mutually developed plan of care with effective feedback loops (36.8%) Of the existing IT solutions highlighted from the break out sessions, the top THREE in terms of improving care transitions for patients and scalability are: Interoperable information exchange , e.g. a model for data repository using Surescripts data + clinical data with displays at the point of care and pharmacies (51.2%) Get a “model” that works and implement it consistently, make sure activity is communicated consistently with patients and providers, and get it to scale with technology (44.3%) More effective risk stratification; make sure that social and clinical factors are incorporated into risk stratification (40.8%) Of the innovation opportunities that would address the most difficult challenges in care transitions discussed in the break out sessions, the THREE that will likely yield the most impact are: Feedback loops when things don’t happen, e.g. appointments, meds etc. (69.3%) EHR / PHR that can merge a medication record, including community pharmacies who provide medication therapy management (47.5%) Optimization of existing technologies to achieve improved care transitions (34.7%) The most important enabler of spread and uptake identified in the break-out sessions is: Move from hospital centric model to a larger team model for support (49.0%)

The meeting ended with “commitment statements” from a diverse set of stakeholders, including a “Two Week Challenge,” after which participants will share more substantial organizational commitments. The meeting featured several ONC-funded Beacon Communities, spotlighting their comprehensive and community-focused use of IT intervention strategies to improve care coordination, collaboration and improve cost savings across the 17 Beacon Communities national network. ONC also announced the new policy standards in areas including technological interoperability that can be applied to multiple health system settings integrating IT innovations.

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Putting the IT in TransITions December 5, 2011 Briefing Moving the Agenda Forward: The meeting hosts have identified many opportunities for attendees and other interest parties to join in on the work ahead.
NOV-DEC 60 days 2 Week Challenge, briefing document; summary materials; Transitions from Hospital to Home Challenge DEC-JAN 90 days Opportunity: Jan 26 Innovation Meeting

JAN-FEB 120 days Opportunity: Care Transitions Bootcamp (TBD)

*Continuous: Health Affairs Innovation Stories, Health 2.0 engagement in challenges What People are Saying: Putting the IT in Care TransITions by Natasha Beauchamp on Elder Pages Online Putting the 'IT' in Care Transitions by Brian Ahier on Healthcare, Technology, and Government 2.0 Mostashari: 'Our healthcare system is in trouble' by Diana Manos on Government Health IT How HIT Can Make Care Transitions Safer by Gienna Shaw on HealthLeaders Media Stakeholders Eye Health IT Tools To Improve Care Transitions on iHealthBeat Putting the IT in Transitions ONC Event by Roberta on HITechAnswers Stakeholders brainstorm on improving healthcare transitions with IT by Diana Manos in Healthcare IT News Putting the IT in Care TransITions by Amy Berman on health AGEnda. Putting the IT in TransITions by Shannah Koss on Disruptive Women in Healthcare. A Patient’s Perspective on Improving Care Transitions by Donna Cryer on DC Patient. Pipette is in DC - Care Transitions and Technology by Pipette on Pipette Company Blog. Putting the IT in TransITions at #KPCTH #ITrans by Mark Scrimshire on HealthCamp Foundation How Technology Can Ease Care Transitions by Garalyn Magan on LeadingAge

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Email hit.caretransitions@gmail.com or click on the following links for more information: Press release: Kaiser Permanente Center for Total Health Sign-Up to the contact list to received key findings 10/14 photos, 10/14 video interviews, and TransITions 2+1 videos. [Type text]