Improving Coordination During Care Transition between Ambulatory and Inpatient Care Facilities: Evaluating the Utilization and Scope of Ehr Facilitated Longitudinal Plan of Care


  • Reena Rachel George
  • Tamara J. Winden
  • Laverne Manos
  • Angella Herrman
  • Maritza Campos
  • Colleen Booz Dittrich



Care transition; Electronic Health Record; Longitudinal Plan of Care; Care coordination; Inpatient care setting; Ambulatory care setting


Gaps in generation and timely transfer of relevant information during care transitions remain a great
challenge to care coordination. Electronic Health Record (EHR) based information transfer tools are not
efficiently used by most providers. The objective of this project was to understand the current process of care
transition between ambulatory and inpatient care setting and to explore the utilization and scope of an EHR
based Longitudinal Plan of Care in improving coordination during care transition. The Longitudinal Plan
of Care when compared with transition of care practices recommended by Transitions of Care Consensus
Conference and National Transitions of Care Coalition work group showed that it lacked some information
pertinent to care coordination. The survey performed indicated that most commonly used Electronic Health
Record tool for care transition were notes and chart reviews (97.4%, 93.4%). Only 12% of the participants
expressed high satisfaction with the currently used tool. Among the participants who used the Longitudinal
Plan of Care, only 8.8% reported it as a sufficient tool for information transfer. Majority (93.5%) were
unaware that such a tool existed and had never explored its functionality. Improving the functionality of
Longitudinal Plan of Care and training health care providers can greatly facilitate information transfer
during care transition.

Author Biographies

Reena Rachel George

Research Fellow, Department of Health Informatics, KU School of Nursing

Tamara J. Winden

Chief Research Informatics officer Center for Medical Informatics and Enterprise Analytics, Assistant Professor, Department of Internal Medicine

Laverne Manos

Clinical Associate Professor, KUMC Center for Health Informatics, KU School of Nursing, The University of
Kansas Medical Center

Angella Herrman

Clinical Informatics Specialist,The University of Kansas Health System

Maritza Campos

Clinical Informatics Specialist, The University of Kansas Health System

Colleen Booz Dittrich

Director of Continuum of Care, The University of Kansas Health System