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The American Journal of Managed Care January 2019
The Gamification of Healthcare: Emergence of the Digital Practitioner?
Eli G. Phillips Jr, PharmD, JD; Chadi Nabhan, MD, MBA; and Bruce A. Feinberg, DO
From the Editorial Board: Rajesh Balkrishnan, PhD
Rajesh Balkrishnan, PhD
The Health Information Technology Special Issue: New Real-World Evidence and Practical Lessons
Mary E. Reed, DrPH
Inpatient Electronic Health Record Maintenance From 2010 to 2015
Vincent X. Liu, MD, MS; Nimah Haq, MPH; Ignatius C. Chan, MD; and Brian Hoberman, MD, MBA
Impact of Primary and Specialty Care Integration via Asynchronous Communication
Eric D. Newman, MD; Paul F. Simonelli, MD, PhD; Shelly M. Vezendy, BS; Chelsea M. Cedeno, BS; and Daniel D. Maeng, PhD
Mind the Gap: The Potential of Alternative Health Information Exchange
Jordan Everson, PhD; and Dori A. Cross, PhD
Patient and Clinician Experiences With Telehealth for Patient Follow-up Care
Karen Donelan, ScD, EdM; Esteban A. Barreto, MA; Sarah Sossong, MPH; Carie Michael, SM; Juan J. Estrada, MSc, MBA; Adam B. Cohen, MD; Janet Wozniak, MD; and Lee H. Schwamm, MD
Understanding the Relationship Between Data Breaches and Hospital Advertising Expenditures
Sung J. Choi, PhD; and M. Eric Johnson, PhD
Organizational Influences on Healthcare System Adoption and Use of Advanced Health Information Technology Capabilities
Paul T. Norton, MPH, MBA; Hector P. Rodriguez, PhD, MPH; Stephen M. Shortell, PhD, MPH, MBA; and Valerie A. Lewis, PhD, MA
Alternative Payment Models and Hospital Engagement in Health Information Exchange
Sunny C. Lin, MS; John M. Hollingsworth, MD, MS; and Julia Adler-Milstein, PhD
Currently Reading
Drivers of Health Information Exchange Use During Postacute Care Transitions
Dori A. Cross, PhD; Jeffrey S. McCullough, PhD; and Julia Adler-Milstein, PhD

Drivers of Health Information Exchange Use During Postacute Care Transitions

Dori A. Cross, PhD; Jeffrey S. McCullough, PhD; and Julia Adler-Milstein, PhD
Health information exchange offers significant potential to address unmet informational needs during transitions between hospitals and skilled nursing facilities; workflow barriers and design limitations currently limit value.

Objectives: To characterize the drivers of the use of electronic health information exchange (HIE) by skilled nursing facilities (SNFs) to access patient hospital data during care transitions.

Study Design: Explanatory, sequential mixed-methods study. Quantitative data from an audit log captured HIE use by 3 SNFs to retrieve hospitalization information for the 5487 patients discharged to their care between June 2014 and March 2017, along with patient demographic data. Qualitative inquiry included 16 interviews at the discharging hospital and HIE-enabled SNFs.

Methods: Multivariate probit models determined patient-level factors associated with SNF HIE use. These models informed subsequent in-depth, semistructured interviews to refine our understanding of usage patterns, as well as facilitators of and barriers to use.

Results: HIE was used by SNFs for 46% of patients for whom it was available; 29% of patients had records accessed within 3 days of hospital discharge. Overall HIE use was more likely for new versus returning SNF patients (3.8%; P <.001) and when a patient was discharged from the emergency department rather than an inpatient unit (6.8%; = .027). HIE use was less likely on weekends (–4.3%; P = .036) and for more complex patients, as measured by length of stay (–0.4% per day; P ≤.001) or number of conditions (–0.3% per diagnosis; P ≤.001). Interviews revealed distinct HIE use cases across SNFs; perceiving ability to access information not otherwise available in paper discharge materials, as well as workflow integration, were critical facilitators of use during transitional care.

Conclusions: HIE between hospitals and SNFs is underused. A mixed-methods approach is critical to understanding and explaining variation in implementation and use. Creating value requires hospitals and SNFs to codevelop system design, usage guidelines, and workflows that meaningfully integrate HIE into care delivery.

Am J Manag Care. 2019;25(1):e7-e13
Takeaway Points
  • Despite substantial health information exchange (HIE) investment, there has been minimal focus regarding what value-generating HIE looks like to support transitions between hospitals and skilled nursing facilities (SNFs).
  • This novel mixed-methods study explores what prompts SNF providers to utilize available HIE functionality and assesses barriers to effective use.
  • HIE tools are currently underused to support postacute care transitions; usage patterns vary significantly across SNFs within a single community.
  • Community-based hospital–SNF collaborations are critical for codeveloping clear guidelines that promote impactful usage practices; policy efforts can advance system design and processes that enable transfer of data elements specific to the needs of SNF providers.
More than 4 million Medicare patients are discharged to a skilled nursing facility (SNF) annually; these patients tend to be older, have more complex conditions, and are a significant driver of healthcare spending.1,2 Weak transitional care practices between hospitals and SNFs compromise quality and safety outcomes for this population.3-6 In response, numerous payment and delivery system reforms target this transition and create incentives for hospitals and SNFs to collaborate on improvement initiatives.7 A key contributor to poor hospital–SNF transitions is the lack of robust information-sharing infrastructure between these settings, often resulting in missing, delayed, or difficult-to-use information received by SNF providers.8-11 These deficits result in worse patient outcomes in SNF settings (eg, delayed care responsiveness, medical errors) and increased risk of rehospitalization.12-14

Electronic health information exchange (HIE) may help address deficiencies in hospital–SNF information sharing. HIE infrastructure has matured under the Health Information Technology for Economic and Clinical Health Act, with corresponding organizational and regional investments to improve communication and integration across care settings.1,8,15 There is, however, significant uncertainty about if and how HIE supports hospital–SNF transitions, with very little empirical work examining use of HIE by SNFs.16 Understanding what effective HIE looks like in this context is unique, as hospital and SNF providers may prioritize collection of different types of information. For example, SNFs focus on continuity in rehabilitation therapies and improvements to functional status, which are not points of emphasis during an acute hospitalization. Further, hospitals and SNFs also maintain different staffing models, workflows, reimbursement structures, and cultural norms; these discrepancies may increase the difficulty of constructing shared handoff processes that fit the needs and preferences of both organizations.17,18

Identifying factors associated with when and why postacute providers choose to access available HIE functionality will help assess whether current HIE infrastructure is meeting the needs of SNFs and what design or implementation changes could be made to maximize potential value. Therefore, in this study, we used a mixed-methods approach to answer the following research questions: (1) When available, to what extent is HIE used to support postacute transitions? (2) What patient- and encounter-level factors are associated with variation in whether HIE was utilized during a patient’s transition? (3) What SNF organizational factors facilitate or hinder integration of HIE with existing transitional care practices?



Our study examined hospital–SNF HIE between a large academic medical center and 3 local SNFs. In June 2014, the hospital extended a “view-only” HIE portal feature (EpicCare Link) to enable these SNFs to access hospital records for patients discharged to their facility. These SNFs receive the highest volume of the hospital’s discharges to SNF—together, nearly 45% of total referrals. Administrators, nursing directors, and, occasionally, nurse unit managers were granted access. SNF physicians had full access to the hospital electronic health record (EHR) and therefore did not require portal access. This portal access was in addition to standard discharge protocol, which included a paper discharge summary and nurse-to-nurse phone call.

Data: Quantitative

For all hospitalized patients discharged to any of the 3 HIE-enabled SNFs between June 2014 and March 2017, we pulled the following fields from hospital EHR data: patient medical record number, hospital admission and discharge time stamps, basic demographics, reason(s) for hospitalization, diagnoses, medications, and name of SNF to which the patient was discharged. We then merged these data with the audit file of all portal log-ins by users whose access rights were associated with an HIE-enabled SNF. These records are time-stamped and associated with a facility identifier, provider identifier, and medical record number of the patient whose information is being accessed. This study was approved by the health system Institutional Review Board (ID: HUM00123359).

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