Improvement of Electronic Health Record Integrated Transition Planning Tools in Primary Care

The transition from pediatric to adult care is under-studied in primary care. Electronic health record-integrated transition planning tools (ETPTs) can facilitate the transition. We tested whether ETPTs and clinician reminders increase the frequency of transition discussions during adolescent well-visits.

In an academic adolescent medicine primary care practice serving a predominantly African American, Medicaid-insured population, we developed 4 ETPTs-readiness assessment, plan template, information handout, and diagnosis code. We used Plan-Do-Study-Act quality improvement cycles to implement ETPTs and measure outcomes. Each cycle added a new layer of clinician support: (1) ETPT training, (2) visual reminders, (3) incentives, and (4) daily reminders. The primary outcome was the proportion of well-visits in which "any ETPT use" occurred. We collected data via chart review and used run charts and regression analyses with multiple comparisons to detect differences between cycles. Clinicians-provided feedback was elicited.

Any ETPT use increased from 0% to 45% between baseline and cycle 4. The odds of any ETPT use was ten times larger in cycle 4 compared to cycle 1 (odds ratio 10.09, 95% confidence interval 2.29-44.44, P = 0.002) and 22 times larger in cycle 4 than cycle 2 (odds ratio 21.99, 95% confidence interval 3.96-122.00, P < 0.001). Clinicians identified time constraints and lack of sociocultural relevance as barriers to uptake.

Daily reminders combined with training and visual reminders were effective in increasing the use of ETPTs in primary care. Future interventions should adapt existing transition tools to the needs of target populations and create regular reminders to facilitate uptake.