Center for Clinical Translational Research
Current CTR Studies
The Effectiveness of an HIT-based Care Transition Information Transfer System to Improve Outpatient Post-Hospital Care for Medically Complex Patients
(Patient Information Transfer System to Outpatient Providers - PITSTOP)
Improved coordination of care across health care settings and enhanced health information technology have been identified by the IOM as two essential tools for improving health care management during care transitions. Yet health care remains fragmented and poorly coordinated across treatment settings, often resulting n preventable medication errors, unnecessary hospitalizations and emergent care visits, avoidable adverse health events and dissatisfied patients and providers. Times of care transition can be particularly difficult for the medically complex patient, particularly in rural communities. The objective of this project is to improve the process by which crucial hospital discharge information is communicated to rural patients and their outpatient rural primary care providers.
The Agency for Healthcare Research and Quality (AHRQ) recently awarded Billings Clinic Center for Clinical Translational Research a three-year 1.2 million dollar grant to conduct a research study to improve communication with local physicians regarding the hospital discharge of patients with medically complex conditions who live in rural areas.
The goals of this project include the development, implementation and evaluation of a care transition information transfer (CTIT) system. The system will rely on the current integrated electronic health record (EHR) in a large non-profit community health system and will include electronically generated:
- Comprehensive patient discharge instructions, including a patient-friendly medication list, provided to the patient at time of discharge and sent to the rural outpatient provider clinic
- Discharge information transmitted to rural outpatient providers regarding their high-risk patients.
- Rural providers will also be prompted to access more complete medical information by connecting directly to the hospital’s EHR.
- Program evaluation will focus on specific clinical outcomes, such as patient adherence to medication instructions after discharge, patients receipt of reconciled medication lists, hospital readmission rates, and utilization of emergent care services; system efficiency outcomes, such as time to first patient ambulatory setting visit; and rural patient/family and inpatient/outpatient provider satisfaction.
In addition, patients will receive more information regarding their medications, tests, procedures, follow-up appointments with their rural providers, and educational information about their medical conditions. The objective is to empower patients to take an active role in their medical care at time of hospital discharge and in understanding their medications.
Participating rural communities:
- Billings Clinic Cody, Cody, WY
- Colstrip Medical Center, Colstrip, MT
- Billings Clinic Columbus, Columbus, MT
- Gabert Clinic, Glendive, MT
- Park Clinic, Livingston, MT
- Billings Clinic Miles City, Miles City, MT
- Billings Clinic Red Lodge, Red Lodge MT
- Roundup Memorial Healthcare, Roundup, MT