Supporting Care Transitions through Expanded Use of an Electronic Personal Health Record

Washington Care Transitions Program


Northwest Regional Council’s Aging & Disability Resource Center (ADRC) implemented the evidence-based hospital-to-home Care Transitions Intervention® (CTI). The ADRC partnered with Whatcom County Health Information Network (HInet) to expand use of an electronic personal health record and communication tool to enhance outcomes for the care transition participants. The electronic PHR is free for residents of two counties targeted by the ADRC’s CTI program. The electronic PHR was implemented with care transition participants or their informal caregivers to provide a person-centered approach for the care-team in order to promote and facilitate positive health outcomes.

A curriculum was developed by HInet for ADRC staff to assist Care Transition grant participants and other community members in the registration and use of the Shared Care Plan. The ADRC increased community awareness of the innovation and the importance of maintaining a personal health plan through 46 community presentations. Forty-seven Care Transition participants and 254 additional community members were provided information about and access to both hardcopy and electronic forms of the PHR. All Care Transition participants and 247 additional community members (294 total) were assisted to completed PHRs.

Surveys were distributed to all 294 participants, with 30 (10%) responding. Primary results indicated a mixed response for using the electronic PHR and a positive response for using the paper PHR. It was observed that the CTI intervention of using an electronic Personal Health Record was somewhat unclear and intangible to participants immediately upon discharge from the hospital. Providing information about the Shared Care Plan (as part of the CTI intervention) and engaging the participants by providing a paper version of the Shared Care Plan made the personal health record tangible.


  • Washington State Department of Social & Health Services (DSHS) Aging & Disability Services Administration (ADSA)
  • Northwest Regional Council (NWRC) Aging & Disability Resource Center (ADRC)
  • Whatcom County Health Information Network (HInet), LLC (
  • Congral, LLC ( – primary developer of the PHR


Problem Addressed: Patients and their family members or others in their small social network bear primary responsibility for communicating their health information and managing it from care site to care site.

This is true in Whatcom County where there is 80% adoption of Electronic Medical Records by clinicians. Unfortunately, that 80% adoption occurs through use of more than twenty different EMR systems, which don’t exchange information. Connection to health information resources and the Microsoft Health Vault platform facilitate better self-management through education and ability to import data from other EMR systems, lab systems and home monitoring devices such as glucometers, blood pressure cuffs, and scales.

The program addresses the need for adults transitioning from hospital to home, often with medically complex situations, to establish and keep active a personal health record (PHR). A PHR is one of the four pillars toward success in the evidence-based Care Transitions Intervention Program (CTI) and is used as a communication and tracking tool in an effort to reduce the risk of re-hospitalization. The Shared Care Plan (SCP) is an electronic medical document where clients and/or their caregivers can manage their information through an on-line system. Having an electronic PHR provides a means for the patient or his/her caregiver to exchange information more efficiently with healthcare professionals in support of better health outcomes, including reducing the risk of re-hospitalizations.

In addition to care transitions participants, the general community is ill-prepared for a hospital stay and the transition back to home. Knowledge about, and participation in, an electronic PHR accessible to individual’s circle of caregivers, community supports, and healthcare providers could enhance communication, improve care, and relieve stress upon admittance to a hospital.

Patient Population: The program was developed for older adults and persons 18 years and over with disabilities in Whatcom and Skagit Counties, including participants in Washington State’s Administration on Aging-funded Option D Evidence-based Care Transitions Grant; and other interested community members.

Description of Program: 

ADRC Activities: 

As part of the Care Transition Intervention activities, the Shared Care Plan (SCP) was included as an option for the Personal Health Record that is typically used in the evidence-based care transitions model. Coaches would meet directly with clients and family caregivers to explain the use and usefulness of the PHR tool. In order to facilitate understanding of the components of the SCP, coaches would also leave a modified hard copy, paper version of the SCP with the client to use to gather their health information prior to adding it to the electronic version. For individuals requesting more help, ADRC Specialists provided one-on-one assistance/training to populate either the paper or electronic version of the PHR.

In addition to the above, ADRC Specialists and other NWRC staff conducted trainings throughout the target geographical areas about pre-admission planning for hospitalizations using a program called “Hospital 101”. This program was provided to a variety of groups of older people including retired employee associations, communities of faith, senior centers, clinics, caregivers, tribal groups, and professionals in social work and health. As part of this presentation, the establishment of a Personal Health Record was emphasized and hard copy documents distributed as well as electronic registration documents provided for those interested in the on-line system.

Using both of these routes to expand the use of the program, 301 people received information about the importance and use of the SCP. CTI clients, in general did not take advantage of the opportunity to enter their health information into the electronic PHR, but instead overwhelmingly chose the paper version.

HInet Activities: 

HInet staff conducted Train-the-trainer sessions for ADRC Specialists so they in turn could train CTI participants and other community members in the advantages and use of the electronic Shared Care Plan.

HInet also supported ADRC staff to assist individuals in registering and completing electronic Personal Health Records with internet capable wireless devices (laptops and iPads); paper forms to facilitate information gathering; and onsite personal and telephone support.


Patient Recruitment and Uptake:

  • Total number oriented on the benefits and advantages of an electronic PHR = 301
  • Total number assisted to complete a Personal Health Record = 294
  • Total number with an account for an electronic PHR= 19
  • Total number with an electronic PHR = 11
  • Total number Option D CTI participants initiated in Whatcom and Skagit Counties (February-December 2011) = 154
  • Total number CTI participants assisted with a PHR (paper or electronic) = 47
  • Total number CTI participants assisted to successfully create an electronic PHR = 1
  • Number Outreach/Education Events: 46

All CTI participants were offered assistance with the electronic PHR; however, approximately 75% had no access to a computer or the Internet; many were fearful of entering personal identifying information; and most who attempted became discouraged early on with the registration process. Data on number of online accounts and those signing in to create PHRs were supplied by HInet.

Survey Results from Recruited Patients

  • Total number of surveys distributed = 301
  • Total number of surveys returned = 30 (10%)
  • 7 respondents indicated using the electronic PHR; 8 indicated using the paper PHR; and 5 did not respond to this question.
  • Questions about creating, using, usefulness, maintaining, and sharing the tool were mixed for those using either the electronic or paper PHR.
  • Top four reasons for not using the electronic PHR were: (1) Found Tool Confusing; (2) No Access to Computer; (3) Concern for Privacy; and (4) Do Not Understand Computers.
  • When asked if they would recommend the tool to others, respondents were very positive about the paper version, but were less inclined to recommend the electronic version.
  • Some suggestions for improvement included:
    • Make it easy to log into and use
    • Expand so other healthcare providers can access my information
    • Concerned about choosing the right medications on the list – don’t want to make a mistake


Context of the Innovation: Several local factors that served as an impetus for this program. In 2001, five provider organizations in Whatcom County Washington took up the challenge of the Institute of Medicine Report, Crossing the Quality Chasm, to develop a system of chronic care whose goals were to meet six aims: Safe, Timely, Effective, Efficient, Equitable, and Patient-Centered care. This effort was stimulated and aided by the Robert Wood Johnson Foundation’s Pursuing Perfection Grant. Patients, family members and professionals participated in the design of a system that would achieve self-management and communication among care team members; and the Shared Care Plan evolved into the current web based application by employing user-centered design methodologies. Further refinement of the application has been made possible through grants from the Agency for Healthcare Research and Quality (AHRQ), the Foundation for Health Initiative (HRSA OAT), HRSA grants, and the ongoing contributions and efforts of PeaceHealth, a network of health communities in the Pacific Northwest. The tool is free to individuals living in Whatcom and Skagit counties.

HInet participated in the Washington State Healthcare Authority’s (HCA's) health record bank (HRB) pilot project which was developed and implemented to address the problem of no Lead Organization responsible to securely collect and assemble consumer's comprehensive health information so that it can be accessible by consumers when and where it is needed. Initial HRB implementation was modest in 2008 and 2009 to test viability and consumer interest. At that time HRBs provided three to five items of data to consumers through a personal health record (PHR). The Shared Care Plan PHR and Microsoft HealthVault provide the technical infrastructure for HInet’s Health Record Bank. Significant progress has been made in the three state HRB communities and the Department of Defense Madigan Healthcare System HRB (MHS). Established objectives were substantially achieved with renewed consumer enrollment efforts now underway. The HRBs have also added more sophisticated applications such as cell phone text-enabled registration, planned for in the Community Choice HRB, and an iPhone HRB application available to consumers in Whatcom County in the St Joseph HRB.

A CMS 9th scope of work contract with Qualis Health (the Beacon Regional Extension Center) allowed HInet to develop a Workflow Assisted Care Transitions software module building upon the infrastructure of HInet and the Shared Care Plan.

Planning and Development Process:

The planning and development process benefited by pre-planning with program collaborators. Input was obtained on how to enhance participants’ experiences and outcomes as part of the state’s AoA-funded ACA Option D Evidence-based Care Transitions grant. Online meetings were used to ensure ongoing progress reporting, problem solving, and discussions of possible innovations. At certain points additional resources were tapped to ensure observations either matched expectations and/or needed interventions.


Getting Started With This Program: It is imperative that the program team commit to honest, shared, and facilitated root cause analyses of the challenges they face; and to collectively improve their approach and delivery. Differences, ground rules, and communication channels should be ironed out at the beginning to establish shared goals, objectives and how success will look. Taking the time to do frequent check-ins and re-establishment (or revision) of project parameters will help maintain focus on the end results.

For successful engagement with interested patients/consumers, dedicated staff is needed to provide one-on-one education, training, assistance and ongoing support. Individuals going through transitions are often challenged by the numerous individuals coming in and out of their lives and homes.

Security concerns can become a large barrier to expanded use of an electronic PHR. There needs to be a way to address this not only from the technological perspective, but also from the consumer education perspective so consumers are knowledgeable about when and where they are relatively safe to share personal health information, and how to protect themselves.

Sustaining This Program: The Shared Care Plan application is continuing to be used and supported in Whatcom and adjacent counties. Its ongoing operation is funded through HInet’s access fees. Development of new functionality will continue.

Programmatic Considerations:

  • Everything takes longer than anticipated. This is related more to cultural shifts and health care reform than the technology. We are still relatively early in shifting people’s understanding of their role in managing their own health, and communicating how technology can help with that.
  • For older adults and others who unable or unwilling to use online tools and/or computers; significant one-on-one time by a family member, coach, ADRC specialist, or other trusted individual is needed to assist with registration and ongoing updating of an individual’s information. This individual needs to be someone who both likes using the technology, and is willing to spend the time updating. Using a hardcopy PHR can help organize the information for easy input into the electronic tool.
  • Often, older adults are much more comfortable with a paper hardcopy tool that they can write notes on and maintain as they need to. Although the PHR in this innovation had an easy to use print option, it still was a barrier for those unused to technology.
  • For individuals who are willing and able to use the technology, one-on-one training, practice, and access to technical assistance are needed to ensure the individual can fully navigate and take advantage of all aspects of the tool.
  • Many older adults have been told numerous times, not to share their Social Security or Medicare numbers. More public education is needed to help them distinguish between secure and unsecure sites and how to protect their personal identifying information online. The challenge for online PHRs is that when this information is NOT input, information sharing among providers and the patient is NOT possible.
  • An electronic PHR tool cannot be viewed as a burden to either patients or healthcare providers, but instead must show evidence at minimum of increased efficiency, and at best improved health outcomes.
  • The PHR needs to be one that physicians consider easy to use. Ideally, whatever they use on a regular basis would automatically feed the PHR without any extra steps. This tool was designed to seamlessly interface with the hospital EHR.
  • Patients often will not use an online tool if their physicians are not interested or do not have access to the PHR. Physicians need to buy into the concept of a PHR. With the burden of many administrative requirements and billing complexities, independent physicians and clinics need something that is affordable and is shown to improve health outcomes.
  • Dedicated resources are needed to support patients in creating and maintaining their records.
  • Increasing numbers of wireless devices will facilitate patients’ entry of data into a PHR, supporting the development of a medical home.

Health Information Technology Considerations:

  • Web-based applications require a fast internet connection and relatively new computer technology to use successfully (a number of staff struggled to log on and use the tool on high-speed, new computers). Older adults were found to frequently use hand-me-down computer equipment which can slow processing time significantly. A new module of the Shared Care Plan supports the workflow of patients and care managers through calendared reminders, communication of red flags, and educational guidance. Patients and their home coaches have positively responded to receiving text messages or e-mails, and care managers have endorsed a dashboard approach to identifying those who need intervention for out of range results or missed activities.
  • IT-enabled design systems should be designed so that they can be accessed and viewed by computer hardware and software which is not state of the art; allow font-size adaptation for on screen viewing; and improve contrast in colors, reverse type, use of fancy fonts.
  • Messages must be kept simple and the process simpler. Logons should not require multiple steps nor require information which is construed by elders to be “off limits”, such as a Social Security or Medicare number.
  • The readability and literacy levels of the health information provided must be assessed. Health literacy varies tremendously and nowhere is that more apparent than in the lives of older adults who are dealing with multiple chronic illnesses. Web applications where substantial health literacy is required to navigate a system means that many elders will either stop using the application, misunderstand the application, or bluff.

Tech4Impact Care Transitions Diffusion Grants Program