Using Health Information Technology (HIT) to Improve Transitions of Complex Elderly Patients From Skilled Nursing Facility (SNF) to Home

2014-07-23 21:11:56 | BioPortfolio


The incidence of drug-induced injury is high in the ambulatory geriatric population, especially for elders with complex healthcare needs during high risk transitions to the ambulatory setting. In a previous study funded by the National Institute on Aging and the Agency for Healthcare Research and Quality [AHRQ] (AG 15979), the investigators determined that drug-related injuries occur at a rate of more than 50 per 1000-patient years in older adults in the ambulatory setting and that 28% are preventable. Independent risk factors for adverse drug events among older adults in the ambulatory setting included advanced age, multiple comorbid conditions, and the use of medications requiring close monitoring. In this project, Using HIT to Improve Transitions of Complex Elderly Patients from SNF to Home (1 R18 HS017817), the investigators are testing the use of an electronic medical record (EMR)-based medication reconciliation system for complex elderly patients transitioning from subacute care in a skilled nursing facility (SNF) to the ambulatory setting. The growing trend for physicians and other healthcare providers to restrict their practices to single settings and not follow complex patients as they move between settings leaves older patients discharged from subacute care particularly vulnerable. This transition is uniquely challenging because of the complex healthcare needs of this population, who often require outpatient primary care physicians to coordinate with visiting nurses in order to manage complex medication regimens and fluctuating clinical status. To facilitate high-quality transitions from the subacute to the ambulatory setting and support interdisciplinary communication, the investigators will use the EMR to assure that physicians in the ambulatory setting and visiting nurses receive key health information and alerts. In order to evaluate the impact of their HIT-based transitional care intervention, the investigators propose a randomized controlled trial with three arms: (1) HIT-based delivery of key health information and alerts to the primary care physician; (2) HIT-based delivery of key health information and alerts to both the primary care physician and the visiting nurse; and (3) usual care.

Study Design

Allocation: Randomized, Control: Active Control, Endpoint Classification: Safety/Efficacy Study, Intervention Model: Parallel Assignment, Masking: Double Blind (Investigator, Outcomes Assessor), Primary Purpose: Health Services Research


Adverse Outcomes


Intervention 1: Electronic medical record (EMR)-based medication reconciliation system, Intervention 2: Electronic medical record (EMR)-based medication reconciliation system, Control Group


Fallon Clinic
United States


Not yet recruiting


University of Massachusetts, Worcester

Results (where available)

View Results


Published on BioPortfolio: 2014-07-23T21:11:56-0400

Clinical Trials [3344 Associated Clinical Trials listed on BioPortfolio]

Implementation Study on Medication Reconciliation Among Pharmacists in Two Tertiary Hospitals in Southwestern Nigeria

This study will assess the current practice of medication reconciliation among pharmacists in the selected institutions with a view to making an intervention to address gaps discovered

Using Novel Canadian Resources to Improve Medication Reconciliation at Discharge

The purpose of this study is to determine if a physician's use of electronic medication reconciliation software when writing a patient's discharge prescription will prevent adverse drug ev...

Impact of Medication Reconciliation Intervention on the Rate of Preventable Adverse Drug Events (ADEs) and Healthcare Utilization

The implementation of a medication reconciliation intervention including: medication reconciliation on admission and discharge, bedside medication counselling and take-home medication list...

Implementation and Evaluation of a Medical Reconciliation Protocol at Brigham and Women's Hospital

An incomplete understanding of patients' preadmission medications and failure to reconcile these with medications ordered in the hospital and at discharge are major, previously unappreciat...

Study of Medical Student Use of Templates to Document Outpatient Asthma Care in Electronic Medical Record

The purpose of the study is to measure the effectiveness of a social marketing-based medical education intervention on student use of evidence-based templates for documenting outpatient as...

PubMed Articles [35177 Associated PubMed Articles listed on BioPortfolio]

Higher accuracy of complex medication reconciliation through improved design of electronic tools.

Investigate the accuracy of 2 different medication reconciliation tools integrated into electronic health record systems (EHRs) using a cognitively demanding scenario and complex medication history.

Physical health assessment and medicines reconciliation on admission to an acute mental health unit: a quality improvement project.

Individuals with mental health disorders are at greater risk of physical health problems. Medicines reconciliation reduces medication errors on admission. The aim of this project was to improve compli...

Medication adherence, medical record accuracy, and medication exposure in real-world patients using comprehensive medication monitoring.

Poor adherence to medication regimens and medical record inconsistencies result in incomplete knowledge of medication therapy in polypharmacy patients. By quantitatively identifying medications in the...

The Need for Medication Reconciliation Increases with Age.

Medication reconciliation (MR) at hospital admission, transfer, and discharge has been designated as a required hospital practice to reduce adverse drug events.

Medication exposure in highly adherent psychiatry patients.

Medication exposure is dependent upon many factors, the single most important being if the patient took the prescribed medication as indicated. To assess medication exposure for psychotropic and other...

Medical and Biotech [MESH] Definitions

The formal process of obtaining a complete and accurate list of each patient's current home medications including name, dosage, frequency, and route of administration, and comparing admission, transfer, and/or discharge medication orders to that list. The reconciliation is done to avoid medication errors.

Individuals professionally qualified in the management of patients' records. Duties may include planning, designing, and managing systems for patient administrative and clinical data, as well as patient medical records. The concept includes medical record technicians.

Computer-based systems for input, storage, display, retrieval, and printing of information contained in a patient's medical record.

Process of formulating a diagnosis based on medical history and physical or mental examinations, and/or choosing an appropriate intervention.

A system of record keeping in which a list of the patient's problems is made and all history, physical findings, laboratory data, etc. pertinent to each problem are placed under that heading.

More From BioPortfolio on "Using Health Information Technology (HIT) to Improve Transitions of Complex Elderly Patients From Skilled Nursing Facility (SNF) to Home"

Quick Search


Relevant Topics

Drug Discovery
Clinical Approvals Clinical Trials Drug Approvals Drug Delivery Drug Discovery Generics Drugs Prescription Drugs In the fields of medicine, biotechnology and pharmacology, drug discovery is the process by which drugs are dis...

Health care (or healthcare) is the diagnosis, treatment, and prevention of disease, illness, injury, and other physical and mental impairments in humans. Health care is delivered by practitioners in medicine, chiropractic, dentistry, nursing, pharmacy, a...

Pharmacy is the science and technique of preparing as well as dispensing drugs and medicines. It is a health profession that links health sciences with chemical sciences and aims to ensure the safe and effective use of pharmaceutical drugs. The scope of...

Searches Linking to this Trial