As youth with chronic conditions are surviving longer into adulthood, their transition from pediatric to adult healthcare has become a challenge. This transition period is associated with worsening clinical outcomes, including morbidity and mortality, and heightened stress among caregivers and youth. Frameworks for improving the process of transition emphasize the importance of documenting key elements, such as independence goals, transition care plans, care transfer details, and tracking progress. Given the complexity of this transition, detailed documentation is essential to keep track of all this information and enable seamless communication and coordination among health team members. Academic frameworks around transition to adult care provide guidelines around what to track and encourage working within an EHR to develop the best system to achieve these goals.

Through experience in attempting to create a transition documentation tool at Ann & Robert H. Lurie Children’s Hospital of Chicago, it was found that documentation needs to be easy to enter and update through different visits and by various care team members over many years, customizable for each division, easily visible by numerous divisions, allowing for reportable data elements, and live on a patient level. This all needed to be balanced along with ease of build and maintenance. In response, a multidisciplinary team developed a transition to adult care smartform.

The smartform tracks transition preparedness based on the patient’s problem list and age, with questions customized for specific programs like lupus or diabetes. It features discrete data elements that integrate within the EHR, supporting departments tracking population health. For example, data can be queried to determine if a patient has transitioned to an adult provider, aiding the emergency department or transfer center which serve as hospital entry points. Attendees will learn about a potential solution that simplifies documentation of transition to adult care, making it easy to enter, view, and access, while meeting diverse needs across healthcare tams and facilitating reporting and data tracking.

Quality measures included clinician satisfaction, user knowledge of transition documentation, and documentation accessibility. A pre- and post-go-live survey were conducted in the pilot divisions of genetics and rheumatology, with responses from multiple disciplines, including advanced practice providers, genetic counselors, physicians, nurses, registered dieticians, and social workers. Regarding clinician satisfaction, 61% of respondents (n=24) were dissatisfied with their existing workflow. After the smartform’s introduction, 100% expressed satisfaction with the new process, which has currently been used on 33 patients.

User knowledge of transition-related documentation was also surveyed. Before the smartform, 44% of users were unsure where to document transition-related conversations, but after go-live, 100% “strongly agreed” that the smartform met their needs. Regarding accessibility, 43% of users reported difficulty finding their own documentation while 57% could not find other individual’s documentation. Post go-live, 100% of users found both their own and other individual’s documentation easy to locate. As the smartform has become a documentation standard, it will expand to more divisions, and pre- and post- surveys will continue to measure outcomes.

Karolina Malecki MSN, RN, NI-BC, CPN

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