Electronic health records and care coordination across healthcare settings

¶ … care in regards to EMR when patients go from outpatient to inpatient to specialists

Effective Communication

The CMS (Centers for Medicare and Medicaid Services) uses the phrase 'care transition' to refer to patient transference between care settings (like hospitals, nursing facilities, home care, primary care, specialist care, or long-term patient care). Care coordination throughout the continuum of healthcare proves critical to patient treatment management, execution and assessment. Transferring health information of patients from one care location or level to another during patient transfers guarantees care continuity and fosters effective patient treatment. Direct communication between different healthcare providers is vital to smooth patient transition across healthcare settings. Partial knowledge of patient health details and absence of an EHR (electronic health record) that may be accessed anywhere will restrict acute care professionals' capacity of accessing the patient's community pharmacy and ambulatory care records, especially if the professional is not the patient's primary care practitioner (Mansukhani, Bridgeman, Candelario, & Eckert, 2015).

Medication Reconciliation

While treating a patient, the attending clinician might hold, discontinue, or adjust the dosage of outpatient medicines as required, for optimizing or managing treatment. Hence, reconciliation of discharge medication proves crucial to preventing mistakes and ensuring communication after the patient leaves the acute care setting. The process comprises of repeating admission reconciliation before discharge or patient transition between care settings. An estimated 42-82% of discharge medicine lists of patients show a minimum of one discrepancy. Such incorrect information can cause inappropriate care transitions. It is a key factor contributing to elderly patient re-hospitalizations. Healthcare professionals must have adequate time to communicate with their patients so that they can identify barriers like cognitive defects or poor health literacy among patients and seek ways to surmount them. Correct medication reconciliation and other effective transitional services are instrumental in bringing improvements to outcomes-based healthcare delivery, decreasing re-hospitalization rates, and lowering overall healthcare sector costs. A growing pool of evidence suggests that patient medication reconciliation improves treatment outcomes and patient satisfaction, among patients transferred to home or other post-care sites from acute care settings. In-depth and clear-cut patient-provider communication represents the key factor in achieving optimal patient care transition. This includes home visits, post-discharge phone calls, and tele-health services (Mansukhani, Bridgeman, Candelario, & Eckert, 2015).