Clinical Documents: Their Critical Role in Care Transitions

Secure and seamless exchange of clinical information is required to successfully coordinate care across settings in an informed manner. Having this patient information during care transitions is especially crucial to prevent gaps in care and support better-informed decision-making. Clinical documents contain the information care teams require to ensure patients receive appropriate, timely care and to reduce the risk of adverse and costly outcomes like a hospital readmission, but exchanging these clinical documents in near real time is not an industry-wide standard yet.

In this article we’ll look at the challenges around care transitions, the role of clinical documents in supporting better care coordination, and how technology solutions can enhance the process.

The Importance of Clinical Document Exchange During Transitions in Care

Care transitions are critical junctures in the patient care journey when they are moving from one care setting to another and switching to new care providers, and as a result, these transitions are at greater risk for errors or information gaps. Ensuring that providers have access to up-to-date, complete patient information is crucial to preventing avoidable problems during care transitions that could lead to gaps in care, health complications, or hospital readmissions.

Clinical documents contain detailed information collected during patient healthcare encounters and may include Continuity of Care Documents (CCDs), discharge summaries, clinical visit summaries, emergency care summaries, hospital encounter summaries, and more.

When a patient is admitted, discharged, or transferred from a hospital or acute care facility, the treating provider documents the encounter and the care plan within the electronic medical record (EMR). That information can then be extracted and shared in the form of a clinical document with other providers.   Without access to this supplemental data the patient’s care team will have to search for this important information to avoid things like duplicate testing or medication mismanagement.

Seamless exchange of clinical documents supports safer care transitions and better outcomes for patients. When clinical documents don’t reach other providers on the broader care team, it becomes difficult to conduct timely follow-up and can impact treatment as well as quality of care.

Chart Chasing: Challenges with Clinical Document Exchange

Although clinical documents are vital to safer care transitions, accessing them has not always been straightforward for health care providers. Clinical document retrieval has often required care teams to call the acute care provider, request a paper fax, login to separate systems, or even wait to receive it via regular mail.

Other than manually requesting clinical documents from the acute care provider, there are national networks for clinical data query. For example, Carequality has compiled a nationwide registry of healthcare providers who share health data via the Carequality Interoperability Framework, enabling nationwide clinical document querying and retrieval. This option allows for a single location to concentrate chart chasing efforts, which makes operational efficiencies a little better.

However, querying these national networks also takes time for providers to ensure they are searching for the correct clinical document and then sorting through large amounts of data to find it. This is another form of chart chasing and the subsequent delays can create gaps in care and missed opportunities for proactive interventions that could improve outcomes and reduce readmission risks.

Technology for Automated Clinical Document Retrieval

Automating clinical document retrieval is an ideal solution that leverages current technology capabilities to send the information directly to a follow-up care provider’s system when one of their patients has an acute care encounter like presenting at the emergency department or being hospitalized. Equipped with more timely information about a patient’s status and recent healthcare encounters, care teams can make better-informed decisions at the point of care.

For Pathways Health Partners, an accountable care organization (ACO) in Florida, it was a challenge to ensure providers could gain timely access to information about patient healthcare encounters across the care network. Pathways worked with PointClickCare to send real-time admission, discharge, transfer (ADT) alerts directly to primary care provider workflows for more effective and timely follow-up care.  The ADT data feeds are layered with clinical information from discharge documentation and other relevant clinical information to support safer care coordination and to reduce the time providers spend chart chasing to access this critical patient information. By automating access to information from clinical documents, Pathways was able to reduce costs for hospital readmissions and increase the value they can offer across the organization.

Automated clinical document exchange helps to ensure successful care transitions, higher quality patient data at the point of care, and both time and cost savings. When providers can spend less time looking for information they need and more time caring for patients, health outcomes, as well as provider and patient satisfaction, improve.