Having complete and accurate healthcare information is critical in all stages of the patient care process, and many hospitals and physician practices rely on medical transcription companies to ensure this. Care transitions involve many challenges and clear, accurate, relevant and up-to-date medical history should be readily available to clinicians when patients move from one setting to another.
“Transitions of care”, as defined by the Joint Commission, refer to the movement of patients between health care practitioners, settings, and home as their condition and care needs change. Accurate documentation of information is a key requirement for patient safety and quality of care during these patient handoffs. Providers can improve patient care transitions by ensuring up-to-date medical history and streamlining data exchange using technology, according to a recent article published by McKnight’s.
Causes of Ineffective Transitions of Care
Let’s first take a look at the root causes of poor-quality care transitions as listed by the Joint Commission and industry experts.
- Communication Breakdowns: To ensure safe, continuous and coordinated care, there must be effective communication between clinicians and across multidisciplinary teams when patients are transferred from one setting to another. However, there is an increased risk of information being miscommunicated or lost during patient handovers. This can happen due to various reasons: differences in expectations between senders and receivers of the patients, lack of teamwork, absence of standardized procedures and not having enough time to successfully complete the hand-off.
- Patient Education Breakdowns: Patients may not understand their medical condition and as a result, the importance of following their care plan. It can also happen that patients or caregivers don’t get clear instructions about follow-up care, or receive conflicting instructions, confusing medication regimens, and unclear instructions about follow-up care. Sometimes, patients and caregivers are left out from the planning of the transition process.
- Accountability Breakdowns: When many specialists are involved in the patient’s care, no physician may take responsibility to ensure that the patient’s healthcare is co-ordinated across various setting and providers. This can create confusion for the patient and the clinicians responsible for the patient handover.
- Poor Documentation: Poor documentation is one of the root causes of ineffective patient handoffs. Lack of proper documentation can lead to higher rates of readmission to hospital, failure to follow up after hospital discharge, increased costs related to poor care coordination, unavailability of critical diagnostic results, and medication errors.
According to the McKnight’s article, technology can help ensure that all patient care providers have up-to-date medical history and other relevant information quickly and easily to provide the best care during the patient’s care journey. The report provides three recommendations
- Implementing a cloud infrastructure to enable providers to connect electronically with other care providers and exchange the right documentation quickly and securely.
- Using health data exchange to improve communication and data transparency can help providers offer seamless, patient-centered care, regardless of the patient’s location.
- Last but not least, educating staff and clinicians about the benefits of smooth communication and data exchange throughout the transition.
With the COVID-19 pandemic, urgent and rapid transitions in and out of care settings has become common. Ensuring that all care providers have the right information using technology can improve transitions.
“We have now entered into a new normal in senior care and providers simply need to share data in order to drive better health outcomes, says the author, Travis Palmquist, vice president and general manager of Senior Living at PointClickCare.
A report from Deakin University, Australia identified the minimum information elements to support seamless communication at transitions of care for patients with complex healthcare needs as:
- patient details
- family and caregiver support details
- document author and location
- document recipients and location
- encounter details
- problems and diagnosis
- clinical synopsis
- relevant pathology and diagnostic imaging investigations
- clinical interventions
- medications
- allergies and adverse drug reactions
- alerts
- arranged services
- recommendations for management
- information provided to patient, caregiver and family
- nominated primary health providers
Outsourced medical transcription services can play an important role in ensuring that these details are readily available in all settings and every stage of care. A reliable medical transcription company can provide accurate and timely documentation of history and physical reports, discharge summaries, operative notes or reports, and consultation reports and more, which are critical for workplace efficiencies, and to improve care outcomes and ensure seamless engagement across clinicians and healthcare staff treating the patient.
