independent applications to compensate
for the current deficiencies of EHRs with
respect to TOC tools.
Finally, secondary uses of Framework
tracking data could include aggregation of
data about facilities, providers, transport
carriers, health conditions, and methods
for comparative effectiveness research.
Robust, anonymized data could produce
insights about patterns, solutions, and pitfalls for institutional, public health policy
or research.
THE ELEMENTS OF THE FRAMEWORK
The 16 elements listed below are intended
to be an exhaustive set of considerations
to help execute successful transitions, and
analyze failed ones in any setting. Not every
element in the Framework needs explicit
management in every scenario. For example, the default value of patient consent
and voluntariness (part of the Authority
Element) is “nominal” when a conscious,
competent adult leaves the ED after a laceration repair. However, this same element
needs explicit attention if a suicidal minor
child of divorced parents needs to be placed
under a behavioral health hold.
Effort was made to keep the elements
as distinct as possible, but some overlap is
unavoidable. For example, medical records
(part of Information Payload) inevitably
duplicate data in some other elements.
Every element of a transition has obstacles, risks and failure modes. Table 2 shows
examples, but is not exhaustive.
1. Initiator. Who is initiating the transition? This can be the patient, provider,
another authorized party (e.g., parent,
law enforcement, ambulance service) or
undefined. The Initiator is responsible for
the decision and the outbound transition
package.
2. Receiver. Who is receiving the person, payload, responsibility, and tasks?
These may be apportioned among several
parties. However, authority and responsi-
bility should not be uncertain or ambiguous
among a team of caregivers. The Receiver of
a discharge to home is normally “self,” or
patient and family. A significant cause of
failure in discharges to home is inadequate
assessment of readiness, lack of prepara-
tion of the environment, incomplete patient
knowledge, or unavailability of equipment.
3. Person(s). Who is being transferred?
A care transition is a patient-centered
experience. This usually implies definitive
identification and knowledge of personal
characteristics, such as functional status,
mental status, legal status, vulnerabilities,
risks, language, preferences, etc. Some content may overlap items in “information payload” (which is typically more extensive). In
less common cases, multiple persons may
be subsumed in a transition event (e.g.,
mother and fetus, multiple accident victims, mass immunizations). This category
includes accompanying persons.
4. Information payload. What is the
information being transferred? This may
be verbal, written, or in other form. Content may be instructions, records, images,
forms, clinical summary, tasks, plans,
warnings, or contingencies (“if-then”
statements). The format may be human
or machine readable, structured, unstructured, visual, audible, non-verbal, explicit,
implicit, concise, verbose, obvious, or
ambiguous. Although “information” logically overlaps many other Framework elements, this category is meant to comprise
mainly the patient’s care and treatment.
The Work Group noted that “clinical
summaries” received disproportionate
attention among developers of transition
tools. This is not to undervalue the need
to specify essential data sets for handoffs,
transfers, referrals, discharges, etc. The
summary of clinical data is the most necessary – and often deficient – element of a
successful care transition. The Work Group
emphasizes that it is not sufficient alone;
the other elements of the Framework can
also be critical.
The Work Group reviewed numerous
formats and templates for information
transfer, including structured files automatically extracted from EHRs (e.g., CCD/
CDA/CCR), manually generated forms,
spreadsheets, checklists, and systems
relying on text messages or whiteboards.
It was apparent that no individual data item
is essential for every situation. Therefore,
no attempt was made to define information
needs for any constituency.
The “information” is usually the core element of a successful transition. However,
it is apparent that raw, bulk data does not
fulfill the requirement for information
necessary for safe and effective patient
care transitions. This includes thick paper
charts, unreadable EHR printouts, and
electronic files that require concentrated
human curation.
5. Other (physical) payload. What
physical objects are being transferred? This
includes pathology specimens, personal
property, medical supplies/equipment (e.g.,
wheelchair), medications, and media (e.g.,
CD/DVDs, films, photos).
6. Scope. What is the nature and scope
of responsibility being transferred or delegated to the Receiver? This includes tasks
that may become inherited by the Receiver,
and a record of tasks already completed by
the Initiator. Some responsibilities fall upon
the Carrier during transport. Is patient
care responsibility comprehensive or limited? Temporary or indefinite? Defined by
task completion? Open-ended? Is there a
request for advice only? Assumption of
care? Collaboration? Technical services?
Does the Initiator remain on the case? How
are residual tasks to be addressed? Who is
accountable for follow up?
While a care plan may be found in the
Information Payload, it may contain essential information about goals, responsibilities, boundaries, and endpoints that belong
to this category.
7. Authority. What is the Initiator’s
authority for the transfer? What authority
is being transferred to the Receiver? These
originate from the Person’s understanding
and consent, or legal and ethical exceptions. What are the authority relationships
among Person, Initiator, and Receiver?
How has competence been assessed? Legal
ramifications? What are the Person’s outlook and preferences regarding the transfer? Is there conflict?
8. Transport carrier. What is the transportation carrier/vehicle/method for the
human and physical payloads? The transportation pathway may require multiple
stages, vehicles, or transfers.
9. Planning and preparation. These
are actions by the Initiator or a delegate
