. Author manuscript; available in PMC: 2019 Jul 1.

Published in final edited form as: J Healthc Qual. 2018 Jul-Aug;40(4):236–246. doi: 10.1097/JHQ.0000000000000104

Table 4.

Themes and Illustrative Quotes: HIT characteristics

HIT characteristics to support communication and care continuity
*Interoperability of HIT:* “We need to have a clear-cut way to get a hold of the physicians to get them involved – more involved in the plan of care” [FG3] “a referral from the hospital. I think there should be some sort of link, that you can tap on and see how the patient appeared at the hospital, what was done and how he came home. So, then, from there we can take offers to see what we need to do.” [FG4] “Information about their admission, that particular admission…. being able to pull up information about the patient’s care team and who’s on it” [FG4] “So if we had like better supporting documentation of their history which goes back to same like looking at their past 18 months of their MRN too, we would be able to establish that plan to care better at start of care.” [FG5] “The history of the hospital stay. What went on when the person was in the hospital? A lot of small, little history. What went on when they were hospitalized?” [FG4] “Speaker 5: so you can see how many times they were hospitalized before that if you had access and maybe it was cholesterol first and then down the line it is heart failure, may be to know about the previous admissions. Speaker 4: that’s big, knowing about the previous multiple hospital admissions and how often.” [FG1]
*Functionality of home care HIT systems:* “Coming with the referral is already flagging it for the non-clinical staff saying that if you have 20 start of cares but you don’t have 20 clinicians, these are the five that must be prioritized. So for the non-clinical people, this will alert them.” [FG3] …“if there were discrepancies [regarding medications] if that [was] highlighted right on the dashboard …we would know in that visit that’s what I have to find out…” [FG5] “Speaker 3: Medication is important too because if there is a change, so that would give them a change you know you have to reinforce, well you know, you have taken two Lasix today instead of one Speaker 1: so that might be an alert or something that is pops up to tell you that the doctor’s orders have changed” [FG1] “there is medication vial seen, pharmacy list. Then in other under the reconciliation. What the issue was, was it reconciled yes or no.” [FG6] “Anybody can walk in and understand what’s been going on with the patient right? I don’t have to look back to see …. What’s the weight now?” [FG4] “There’s no -- unless they take a record of it. There’s no way -- they have to go back every note, every note, every note. There’s not like a, if you hit the blood pressure we give you for a graph of what blood pressures were or the weights. That would be a great help.” [FG5] “if we’re able to trend it then we can kind of know is the patient improving, is the patient diminishing, and it will – informs us to intervene or prompt us to refer or to communicate with that physician because of care, because that is what you’re developing, some kind of quick plans.” [FG3] “Int: So how often would it be helpful to have this information? Speaker 2: Every visit”. [FG6] “Speaker 5: I want to access it at any time. Because I may want to look at it tonight because I’m going to see her tomorrow Speaker 3: In case you should be able to, it should be... Speaker 2:I may not in planning on visiting the patient, but I just want to see what’s been going on with them so I want to see that you know especially [pause] the way were going... Speaker 5: You should be able to bring it up whenever, at any time Speaker 2: Within 24 hours of start of care” [FG5] “So say if we have noticed that we have CHF plan and the teaching – the parts of the teaching plan and then as the patient has successfully achieved that goal, you have check or it’s bubbled around something. That’s a visual cue like okay, fine. I don’t have to repeat this. I can move forward because that’s completed. Let me go on to the next goal statement.” [FG6]

HIT characteristics to support communication and care continuity

Interoperability of HIT:
“We need to have a clear-cut way to get a hold of the physicians to get them involved – more involved in the plan of care” [FG3]
“a referral from the hospital. I think there should be some sort of link, that you can tap on and see how the patient appeared at the hospital, what was done and how he came home. So, then, from there we can take offers to see what we need to do.” [FG4]
“Information about their admission, that particular admission…. being able to pull up information about the patient’s care team and who’s on it” [FG4]
“So if we had like better supporting documentation of their history which goes back to same like looking at their past 18 months of their MRN too, we would be able to establish that plan to care better at start of care.” [FG5]
“The history of the hospital stay. What went on when the person was in the hospital? A lot of small, little history. What went on when they were hospitalized?” [FG4]
“Speaker 5: so you can see how many times they were hospitalized before that if you had access and maybe it was cholesterol first and then down the line it is heart failure, may be to know about the previous admissions.
Speaker 4: that’s big, knowing about the previous multiple hospital admissions and how often.” [FG1]

Functionality of home care HIT systems:
“Coming with the referral is already flagging it for the non-clinical staff saying that if you have 20 start of cares but you don’t have 20 clinicians, these are the five that must be prioritized. So for the non-clinical people, this will alert them.” [FG3]
…“if there were discrepancies [regarding medications] if that [was] highlighted right on the dashboard …we would know in that visit that’s what I have to find out…” [FG5]
“Speaker 3: Medication is important too because if there is a change, so that would give them a change you know you have to reinforce, well you know, you have taken two Lasix today instead of one
Speaker 1: so that might be an alert or something that is pops up to tell you that the doctor’s orders have changed” [FG1]
“there is medication vial seen, pharmacy list. Then in other under the reconciliation. What the issue was, was it reconciled yes or no.” [FG6]
“Anybody can walk in and understand what’s been going on with the patient right? I don’t have to look back to see …. What’s the weight now?” [FG4]
“There’s no -- unless they take a record of it. There’s no way -- they have to go back every note, every note, every note. There’s not like a, if you hit the blood pressure we give you for a graph of what blood pressures were or the weights. That would be a great help.” [FG5]
“if we’re able to trend it then we can kind of know is the patient improving, is the patient diminishing, and it will – informs us to intervene or prompt us to refer or to communicate with that physician because of care, because that is what you’re developing, some kind of quick plans.” [FG3]
“Int: So how often would it be helpful to have this information?
Speaker 2: Every visit”. [FG6]
“Speaker 5: I want to access it at any time. Because I may want to look at it tonight because I’m going to see her tomorrow
Speaker 3: In case you should be able to, it should be...
Speaker 2:I may not in planning on visiting the patient, but I just want to see what’s been going on with them so I want to see that you know especially [pause] the way were going...
Speaker 5: You should be able to bring it up whenever, at any time
Speaker 2: Within 24 hours of start of care” [FG5]
“So say if we have noticed that we have CHF plan and the teaching – the parts of the teaching plan and then as the patient has successfully achieved that goal, you have check or it’s bubbled around something. That’s a visual cue like okay, fine. I don’t have to repeat this. I can move forward because that’s completed. Let me go on to the next goal statement.” [FG6]