Rhode Island Quality Institute Transitions of Care

Rhode Island


Rhode Island Quality Institute (RIQI) is a non-profit organization with the mission to significantly improve the quality, safety, and value of health care in Rhode Island. RIQI operates CurrentCare, the state’s Health Information Exchange (HIE). An HIE allows health care professionals to share a patient’s vital medical information electronically and securely. This success story highlights how RIQI developed useful tools for providers that provide timely, accurate, and actionable information to manage patient’s transitions of care.

The Challenge: Historically, provider practices in Rhode Island received patient care transition information in a variety of ways including telephone, fax, or in person when the patient arrived for their appointment with their medical record. Practices had access to plenty of patient information from many different sources, but usually the information was not timely, limiting its value. To improve the timely delivery of data, RIQI invited practices interested in improving data flow around transitions of care to pilot a dashboard.

                                                                                                                                                                                                                                                 Image 1: Admission Alert

The Strategy: To eliminate the care transition data flow challenges Image 1: Admission Alertamong hospitals and other providers, RIQI created a simple dashboard that informed a practice if any of its patients were discharged or admitted to the hospital or emergency room. The dashboard accesses data stored in the HIE and uses Active Analytics for the presentation layer. The dashboard updates when an admission, discharge, or transfer (ADT) event is created in the hospital’s electronic health record (EHR) or registration system and subsequently transmitted to the HIE. The dashboard data refreshes every 45 minutes and provides practices with up-to-date pertinent patient information (see Image 1). The dashboard significantly reduces the time needed to transition patient information from hospitals to ambulatory systems.

The dashboard is the visual component of the system, but either care management alerts or hospital alerts drive the content. Care management alerts include basic demographics, primary care physician (PCP) if indicated, the reason for the visit, and where the visit took place (along with whether it was an ADT). Care management alerts allow practices to enroll all of their patients (panels), so they can receive alerts on all patients, even those not enrolled in CurrentCare. Practices can customize their dashboards to change views and alerts as desired. The dashboard is customizable, and each practice can change their views/alerts as desired.

For practices that do not choose to enroll in care management alerts, the dashboard also provides valuable hospital alerts that eliminate the need for practices to search in multiple places for patient data. Hospital alerts are valuable resources for PCPs and their care teams because when an individual enrolls in CurrentCare, they name a PCP on the enrollment form. When the PCP adopts the alert service, the system automatically sends hospital alerts on all patients who have enrolled and identified that physician as their PCP. If a practice notices that a patient was discharged from a hospital, a practice can reach out and treat the patient accordingly.

Dashboard data can be viewed at an aggregate level (see Image 2) as well as at an individual patient level. This aggregate view helps practices identify patient trends, such as the peak time of the day for patient emergency department (ED) use. If significant numbers of ED visits occur during regular office hours, the practice can educate patients about calling the office instead of visiting the ED. Another example is that most ED admissions after 10:00 p.m. on a Friday night are related to alcohol and/or substance abuse issues. PCPs could use that data to develop an intervention to target that patient population.


                                                                                                                  Image 2: Dashboard Data

Image 2: Dashboard Data



Drilling down into the data on the dashboard (see Image 3) reveals a list of patients who are currently in the hospital or ED, and it shows how many times in the last 6 months that each patient was admitted to a hospital or ED. This data can instantly identify high hospital utilizers.


                                                                                                         Image 3: Dashboard Data Drilldown View

Image 3: Drilldown View


Lessons Learned:

Providers and hospitals need to be more receptive to new data. During the implementation of the dashboard, RIQI met with hospitals regularly and provided them with alert reports; they called it the “alerts-you-would-have-gotten report.” Most hospitals estimated lower alerts than they actually received and were surprised by the higher number revealed by the report. It is important to show facilities and practices their data because they often under or overestimate the actual numbers. By showing current data and data trends, the dashboard provides practitioners with information they can act upon to improve patient care at a practice and the hospital level.

During the pilot, care managers realized they needed to adjust their workflow to respond to individual patient needs and to pursue change at the aggregate level, such as understanding how many patients receive follow-up care after a discharge.

Next-Steps/Future Vision:

Rhode Island is a small state with high patient mobility among health care systems, hospitals, and practices. With the dashboard, practices can easily determine if any of their patients were admitted or discharged from area hospitals, helping to coordinate better patient care. Currently, three practices are piloting the dashboard, with the goal of expanding to at least an additional 30 practices by the end of 2016. RIQI plans to explore the use of dashboards and care management reports with their long-term and post-acute care practices who currently only receive hospital alerts.

Success Story Topic
Data Flow