Why are Transitions in Care so Difficult?

**  This article was originally posted  April 3, 2017 on HQO’s new Quality Forum called “Quorum“.   This is an online community for those interested in and doing quality improvement work in Ontario healthcare every day!


For patients, caregivers and providers alike, a transition in care is often a frustrating experience. When looking at why,  many problems are uncovered. A transition occurs when care is handed off from one environment to another (i.e.: hospital to home), one person to another (i.e.: specialist to primary care) or one program to another (i.e.addiction support to general mental health care). When the process is viewed through a quality lens, one sees huge opportunity for improvement.

Problems with transitions occur in every Quality domain.

Effectiveness – Transitions are often cumbersome, uncoordinated, and rarely automatic. Moving a patient along is like “passing the buck” rather than a seamless hand over. If patient information can be moved quickly and in a standard way, effectiveness improves dramatically

Efficiency – Transitions are often attended to after other urgent issues, when the patient has already left your care and sometimes as an afterthought. Creating a process for handover that is widely and consistently adopted, with as little prompting as possible, is important so that less time and energy is spent in making it happen.

Safety – Every time care is passed there is a chance that important information, knowledge, insight and context could be lost. This is largely due to fractured communication. Communication issues are relatively easy to fix when providers collectively own the problem. Solutions are as simple as a phone call or as technical as moving a complete electronic record from one provider to another.

Patient Centeredness – The healthcare system often puts responsibility for a transition onto the back of the patient (multiple pages printed out by the hospital on discharge, handed to the patient for their next doctor). There is no thought as to their capacity to follow through, especially if frail or sick. Some hand-offs happen without the patient at all, and this too can be a problem. The job is considered done when a summary is sent by regular mail to a doctor “on record”. This may not even be the correct physician for follow-up, and often it arrives too late. Looking at this from the perspective of a patient’s needs, both habits need to change.

Equity – Transitions in care are not consistent, equivalent or equitable across the province. Interestingly they work best in locations where there are tight provider relationships and there is a sense of shared responsibility. A great example of this is in rural towns where a small number of the same providers are doing the work in each environment: hospital, community and home. Patients move between local clinicians who all know each other, and where there is a sense of joint ownership in helping someone. In large urban centres providers are more disconnected and unknown to each other, so warm hand-offs are rare. This is a “reverse inequity” problem where care in the city, often with more resources, has a lower standard than remote communities. Standardized and automated processes for making a transition happen can correct this, and in Ontario were now seeing a move back to “local” with transformation initiatives.

Accessible – When patients arrive home after being in hospital they often experience problems with access to people and resources in follow-up. Their family doctor may not be aware of their hospitalization, for example, or there was no advice on when to see her. Access is improved if the patient’s primary care provider knows immediately that he has been admitted or discharged. Having complete information makes it is much easier to plan nursing care or home visits, and access is vastly improved.

Given all these barriers to an easy transition in care, what can we collectively do to remove them?

There are solutions at our fingertips right now. Most of these focus on maintaining key clinical relationships, with attention paid to direct communication. Integrated technology can address some of the issues related to standardization and ensuring that information is transferred automatically. For example, OntarioMD has deployed two products that bridge the information gap between layers in the system. HRM, or Health Report Manager, moves discharge summaries, test results, consultation notes and more from hospitals and health facilities directly into the EMRs of doctors and NPs in near real time. Often they have this information to work with even before their patient has arrived home. Nested in HRM is eNotifications, which tell us when our patient has been admitted, discharged or transferred, notifies us of Health Links status, and even activates CCAC, as case coordinators simultaneously receive the same alert.

The availability of accurate up-to-date information, and advanced technology that smooths communications between various levels of care goes far in ensuring that warmer hand offs occur. But technology is not a panacea. Nor should it be seen as a substitute for simple yet impactful relationship-based transitions like a hand over call to the family doctor on discharge. Institutions, providers and patients working together are the ultimate integrated transition team. It is our collective job to make this happen and create a culture of markedly improved quality in the process.

The Population Health Quandary: How do we get to where we need to be?


Recently,  Primary Care has been moving toward conversations about how we should approach the health of our patients in a more global way.  Talk of population health is front and centre. We hear that 5% of the people we look after consume 64% of Ontario’s healthcare budget, and that if doctors and nurses would only work harder on prevention we could keep people out of that zone. The key to driving wellness and reducing he burden of disease in a community is to approach it from a higher level, we are told. Clinicians are very comfortable with the discrete interactions we engage in in every day between individual patients and ourselves, but we are less comfortable with consideration of the wellbeing of larger groups or our patient population as a whole.

We feel disconnected from the problem. Why is that??

I was recently asked by a senior government official to answer this question: “What problem are we trying to solve in population health? And what do we need to do to make it happen?” This is a very complex issue and obviously there are no simple answers, but I believe that a few principles would go along way to getting us there if we approached them openly.



1) We need to better understand our patient community. This includes collecting data on a large group of patients over time looking for trends, and analyzing the circumstances that surround their health (or lack of it). It is impossible to accomplish large scale population health change without access to data from multiple sources, and this analysis needs to happen in near real-time. Critical data can obviously be found in  EMR and hospital records, but increasingly we are able to mix it with information on social determinants of health (poverty, employment status, social networks, and support system), environmental factors (pollution, weather changes, infections disease outbreaks), health promotion programs (recreation, sports, education) and even social media data  for very powerful insights. It has been said that data leads to information, then knowledge and then wisdom. With strong analytics in place and some thought on how to act on what we see, we will be able to get to predictions about the value of interventions quickly and accurately.



2) Change in the health of populations cannot be the sole responsibility of the government or clinicians.  Patients themselves must be involved. 99.9% of prevention and care happens without any healthcare provider present at all. It is accomplished by individuals in their homes, and by caregivers assisting with it’s provision. Simply consulting or engaging patients is not enough.  They needknowledge and tools for activation around behaviours that are healthy and adaptive.

And for truly effective population health improvement to occur, individuals must be able to both contribute to and work with their own health data. They need line of sight into the record that captures and holds their story. They need a place to curate and store their self-collected health information. They require access to the the same insights and tools that drive change as much if not more than their physicians and nurses do.

3) Reporting to physicians about best practises and where they stand in relation to their peers is not enough. Doctors have access to reports about their practises now if they request them. This happens through EMR searches, contribution to data cooperatives like CPCSSN, EMRALD, or UTOPIAN, and in reports supplied to primary care providers by agencies like Health Quality Ontario (Primary Care Practice Reports).



When received, the reports are usually viewed with some interest, but they are acted upon for change far less often. Driving insight into action for population health management requires mentorship and coaching, and a relentless quest to answer the question “Why?” as much as “How?” And “Who?”.  This goes well beyond the carrots and sticks of incentives or penalties. It requires a full scale cultural shift.  And at the practice level an organized, validated and robust change management process must be built in.



4) Leadership is required at every level to ensure population health issues are addressed properly. Government, healthcare professionals and patients themselves can champion the cause. Each stakeholder community has a valuable perspective on how to make change happen. When combined, the effect can be profound and long-lasting. We must start with teaching and mentoring to improve understanding of the concepts of population health.  Then evidence of benefit comes from analysis of patient and practice data and the performance feedback that goes with it. The hardest step, though, is to translate insight into action.  Providers need tools and resources to provide care that raises the bar.

This cannot be done off the side of our desks and in our spare time.

Patients need access to their data to understand where they sit compared to others and to help them understand the responsibility that comes with  being part of a larger collective. The health system must also evolve to incubate, promote and sustain the changes that occur. Population health change cannot be relegated to a series of pilot projects. Benefits realized should be made evident as quickly as possible, and how best to scale and spread change needs to be thought about in the basic design of this process.



5) The move to population health analytics is actually not a technology play. It is a decidedly human one. Success depends on belief in the process and understanding of a common goal.  It involves a relentless drive to make individuals and communities much more healthy. Ownership of the work is the responsibility of patients, providers and healthcare planners and participation must be intuitive. It will involve clinics, hospitals, public health agencies, schools and even cities thinking together. We require iterative consultation and creative co-design. There must be some innovation in thought about how we move from individual transactions to care of a community, and how these two are enmeshed. Individual physician/patient relationships can be preserved at the same time as the health of much larger groups is being advanced. If done well this can be a revolutionary shift in how we approach illness and prevention.

A collaborative effort across the spectrum of care will be good for all of us!

Your thoughts and comments are most welcome!

Mature EMR Use: a Twitter Conversation


We have come a long way in Canada in getting physicians to adopt digital records systems in the form of office based electronic medical records (EMRs). In Ontario alone over 11,600 physicians (both family doctors and specialists) have EMRs in their practices and are using them with varying levels of sophistication.

 For many of us, the EMR is our lifeline to our patients.

These systems are the environment in which we physicians spend almost all of our day, recording the patient story, reading and thinking about test results and communicating with their peers externally through the creation of referrals, and internally with messaging systems.  Some clinics are starting to push the boundaries of basic use, though, and this is where the power of digital records systems becomes apparent.  This is not easy work.  The thinking required to move to mature EMR use takes reflection and solid dedicated effort on behalf of physicians, nurses and the staff they employ and is often done off the side of the desk.  We are challenged with advancing mature EMR use in basic concepts of change management.  How do we convince users of the benefit of moving forward?  How do we make the work palatable in the face of all the other demands facing them every day from the clinical, business and system perspective?  How do we do all of this in an already strained system with fewer and fewer payments for participation?

There is a tendency to look to our American neighbors in their advancement of EMR Maturity, but models there have been built on massive incentive payments without necessarily a view to how the change can be sustained.  As well, many clinicians are involved in accountable care contracts with various gain sharing and risk sharing strategies that make the work in maturity more pertinent as there are direct benefits to business groups and a time investment in changing behaviour pays off quickly.  But the Canadian environment is different.

Tomorrow (Wednesday February 10th at 1 pm) I will hosting a  “Tweet Chat” with @HCSMCA.  During the short hour we have to chat we are hoping to explore barriers and opportunities in the advancement of EMR use in our environment, especially the community EMR space.  This applies to both primary care and specialist thinking.  We are posing four big questions to advance the conversation and are hoping that you have some great ideas to promote change.

  • T1: How do you use your EMRsnow? What do you value most in it? As a health professional, patient, researcher, etc.
  • T2: What would the EMR of 2030 look like? Where do we need to get to?
  • T3: What could/should be done w/ the vast data in EMR systems to improve patient care, relationships & the healthcare system?
  • T4: How to move forward/promote the advanced adoption and use of mature EMR systems?

This  promises to be a very interactive conversation about the possibilities of community based EMRs, and how they can be used for truly positive change!


Show Buttons
Hide Buttons