The Massachusetts Department of Public Health led a multi-stakeholder project to develop the Universal Transfer Form (UTF) to promote effective transitions between acute care providers and post-acute care settings such as nursing facilities, home health agencies, community health centers and patient-centered medical homes. The UTF contains medication lists, advance directives, the patient’s functional status, treatment plans, and other data elements required by the next provider of care in order to seamless assume responsibility for the patient. The IMPACT project validated the UTF’s design and then converted the form into an electronic Clinical Document Architecture (CDA)-based tool similar to the CDA-based Continuity of Care Document (CCD).
There are many difficulties with the paper-based UTF. Clinicians within different healthcare settings require different types of information to effectively care for the transferred patient, yet merging all of the data into one paper form can make the form very long and difficult for the clinician to locate critical information. In addition, forms that are faxed or mailed can get misplaced or be in transit when the provider is seeing the patient. Handwritten forms are often difficult to read, and errors can occur as these are transcribed manually into electronic systems. Furthermore, if they are not entered into electronic health records (EHRs), the data these forms contain cannot be transformed into valuable information by decision support and population management systems.
Our solution for meeting these challenges was to create an electronic version of the paper UTF, called the CCD+. An electronic format would vastly streamline the content of the paper version, allowing it to be available when and where it is needed, and displaying its content in a consistent format regardless of which institution generated the form. It can be integrated with existing EHRs or reduced to paper for times when electronic access may not be available, such as during ambulance transport. The goal was to create a CDA template that is essentially an extension to the CCD with the necessary new data fields requested by clinicians from various care settings.
The IMPACT team participated on several national groups to ensure that the electronic form that is generated for this project was in line with all existing and evolving federal standards. Team members participated in the federal S&I Framework conversations about the CDA-based Transfer of Care documents, the balloting for Health Level 7 International (HL7) CDA, evaluation of the Centers for Medicaid and Medicare Services Long-Term Care Minimum Data Set (MDS), Outcome and Assessment Data Set (OASIS) and Continuity Assessment Record and Evaluation (CARE) tools, and were seated on several inter-state EHR interoperability workgroups. This approach allowed all the CCD+ to be adaptable and scalable to other regions within the Commonwealth and to other states across the U.S.; the design specifications may be used by other EHR vendors that wish to adapt or adopt this real-world tested CCD+.
IMPACT Includes the Patient
For an effective care transition, it is essential to communicate clinical data in a way that is both meaningful and understandable for patients and their families. The IMPACT project contracted with a vendor to work with patients and families to develop a software tool that will take the data in the electronic version of the UTF and transform it into consumer-friendly language and format. This easily understood information will then be made available to the patient and/or their family via a personal health record, the provider’s patient portal, or by initially printing it on paper. The architecture of this tool supports future development of translations into a patient’s primary language. The resulting tools will be designed to be adaptable by other states.