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The vision for this blog is to create a community of harmonious professionals across the care continuum who encourage each other in exploring digital media as a way to support businesses and families dealing with elder care.

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Putting the IT in Care TransITtions

Written on October 18th, 2011 by tasha

Anyone who has read my blog for long knows that I am passionately dedicated to helping families engage in the care of their loved ones. The recent focus on care transitions highlights the importance of what I call the “home team” (patient and family) in promoting adherence and recognizing problems before they escalate to a re-admission.

Two weeks ago, in San Diego, I delivered a workshop at the NHPCO Clinical Team Conference on using the Internet safely to collaborate across the continuum. I highlighted ways that providers can share information in HIPAA-compliant fashion, with each other, but ALSO with patients and their family caregivers. The emphasis was on tools that facilitate the four factors that tend to reduce re-admissions, as demonstrated by the research of Dr. Eric Coleman of the University of Colorado:

In my session, I spoke about free online services, such as, that allows providers to create a real time, password-protected medication schedule they can make available to the patient/family. This also includes a calendar and appointment feature, which addresses the first two components of improved care transitions.

I also spoke about, the interactive tool developed by the American Heart Association that covers the last two components for improved care transitions. Heart360 allows the patient/family to record bp, weight, blood sugar, etc. (or download them from tele-monitoring devices). Heart360 also provides real time, dynamic feedback about the patient’s cardiac values with a user-friendly interface that addresses health literacy issues by employing the metaphor of red light (emergency, call the doctor), green light (good to go) and yellow light (caution, a problem is developing, engage in Plan B).

Providers can set up Heart360′s red/yellow/green light parameters. They can also set it up to send them alerts if a patient’s numbers fall outside the normal limits, and to remind the patient of Plan B actions if a yellow light alert is triggered. Through Microsoft Health Vault, Heart360 users can also engage with their providers using its secure email function to ask questions and receive answers. All of these are available for free.

At the NAHC conference in Las Vegas two weeks ago, I attended a session on Home Health and IT. While it was inspiring to hear how things are progressing with provider-provider sharing of information, when I asked about including the patient/family in terms of access to records or participation on the team, they looked at me like I was from Mars. Sigh…

I couldn’t believe the need to include the patient/family was considered such a non-sequitor to the topic. Dr. Coleman’s Care Transitions Study was a seminal piece of research, identifying the problem of care transitions early on and measuring cost-effective interventions with the “home team” that were estimated to save the health system nearly $300,000 in a year. This was not brand new information.The 15 Medicare QIO care transition demonstration projects grew directly out of this study.

After NAHC, and then giving my presentation in San Diego a few days later, imagine my delight when I learned that Dr. Coleman was going to be a guest speaker at a web conference last Friday entitled “Putting the IT in Care TransITions“!

I was not disappointed. (And I’m not from Mars!) There were 4 breakout sessions:

Threaded throughout the discussions were references to the need to have patients/families participating. Recommendations included:

The videos and slides from the conference have been made available via the Web. A search for “itrans” on will give you a feed of om-going commentary.

Many thanks to the conference sponsors (John Hartford Foundation, Kaiser Permanente, Gordon and Betty Moore Foundation), Health Affairs, which will be publishing the proceedings, and Brian Ahier (@aheir) who was the tweet meister of the event. This was a supremely on-target conference. It was also put on in a very thoughtful way, making superb use of technology in terms of helping remote attendees participate through online voting, tweeting, slideshare, etc.

Any health IT success stories to share? Any wishes you would like to see in terms of health IT and care transitions?

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