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In the same hospital where a clinician may now dictate her notes to an ambient artificial intelligence scribe or where a radiologist uses AI to assist in making a diagnosis, a discharge planner is often still sending a patient referral request by fax to a post-acute care provider – in large part because that transition process has not fully evolved with technology and the times.

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Nearly half of Medicare beneficiaries are discharged annually from hospitals to post-acute care – the set of medical and rehabilitation services that people receive after a serious illness, injury or other medical event like a stroke or a hip replacement. In far too many cases, the clinical handoff that follows will be printed on the other end and manually rekeyed into a different system by a nurse who spends 15 to 20 minutes per resident doing it. In many cases, the clinical information – including an individual's medication list and treatment plan – will also be reassessed on arrival to ensure it is as current and complete as possible.

Post-acute care usually takes place at a skilled nursing facility or home health agency, and it serves as a critical bridge between the hospital and home or senior living facility for people who are well enough to be discharged but not ready to function independently.

This transition from a hospital to a post-acute care setting remains the most underengineered handoff in American healthcare. And the consequences are dire, including medication errors, readmissions back to the hospital and high healthcare costs.

The issue is not that the technology is missing. Indeed, technology companies like PointClickCare and WellSky’s CarePort have developed infrastructure capable of sharing patient medication lists, discharge summaries and other key details across settings.

Yet our healthcare system remains far behind in tapping this kind of technology for the transition to post-acute care. Why? The incentives have not been strong enough to invest in making it work.

Skilled nursing facilities, in particular, operate on thin margins with high staff turnover, and few can justify the investment to receive and digest reams of data they are not being paid to use. The hospitals, which do........

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