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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
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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.

Outcome. Our primary outcome of interest is whether a SNF used the portal to access hospital information for a patient discharged to its care. We used time stamps to calculate the time elapsed from a patient’s hospital discharge to any recorded portal log-ins. We then created 2 binary indicators. The first captures use within a broad window of postacute care delivery and takes a value of 1 if portal log-in took place within a 16-day window spanning from 48 hours before hospital discharge (window not to extend earlier than time stamp of inpatient admission) to 14 days post hospital discharge or until the time of subsequent hospital readmission, whichever occurred first. The second, narrower transition window indicator captures activity more directly related to transitional care. This indicator takes on a value of 1 only if first use of the system falls between 48 hours prior to discharge and up to 72 hours following hospital discharge to a SNF.

Factors associated with informational need. We hypothesized that 2 patient-level factors would drive greater SNF information needs and therefore be associated with greater likelihood of portal use. The first is greater medical complexity, measured by age, length of hospitalization, reason for hospitalization, number of diagnoses, and number of medication classes present on the medication list. The second concept is patient familiarity to the provider, which we measured with a single binary indicator for whether a patient is a new or returning patient to the SNF to which they were discharged following the index hospitalization.

We hypothesized 2 additional encounter-level factors associated with degree of information needs. The first is the type of hospitalization that occurred prior to SNF admission, as discharges from an emergency department (ED) or observational unit often lack the designated discharge planning staff and more robust transitional care processes (ie, nurse-to-nurse handoff call, structured discharge documentation) of an inpatient unit.19 The second set of encounter measures is whether the patient was discharged after hours (6 pm to 6 am) and/or on the weekend, when staffing is reduced at both the hospital and nursing facilities.20 During these times, hospital nursing staff may not have the bandwidth to make handoff phone calls. Similarly, SNF nursing managers or support staff may not be available to help make follow-up inquiries in response to information gaps.

Data: Qualitative

We conducted interviews with individuals involved in discharge planning at the hospital and with administrators and nursing staff at the 3 SNFs initially enabled with portal access in 2014. We also conducted interviews at 1 additional local SNF that received portal access in 2017. Interviews took place in February and March 2018; they were conducted in person and recorded, then transcribed. Hospital interviews were all conducted one-on-one, and SNF interviews were conducted in a group setting, with a minimum of 2 respondents per facility. Speaking with multiple respondents per site provided a range of perspectives based on role (ie, clinical vs administrative) and organizational tenure. Interviews lasted 30 to 60 minutes. Respondents were asked to reflect upon factors that drive variation in perceptions of unmet informational need during care transitions, motivation to use the portal versus other mechanisms of information retrieval, and ease or difficulty of using the portal to support postacute care delivery. The protocol was designed to explicitly probe respondents on perceptions of portal use and usefulness in response to each of the patient- and encounter-level drivers of informational need identified and tested in the initial quantitative analyses. (See eAppendix [available at] for full protocol.)

Analytic Approach

We used an explanatory sequential mixed-methods design. First, we generated descriptive statistics of HIE use across all SNFs and by individual facility. Key descriptive measures included patient-level system access rate (overall and by year), average time to first view of the HIE system (relative to hospital discharge), and percentage of sessions initiated within the transition window defined above. We then conducted bivariate analyses that compared descriptive statistics on all patient-level “informational need” covariates described previously across HIE-use and non–HIE-use patients. Finally, we ran pooled multivariate probit models with SNF-level fixed effects to regress HIE use on all patient-level covariates identified as significant from the bivariate analyses. We ran separate models for broad versus transition window use outcomes.

We approached our interview data using grounded dimensional analysis to deconstruct interactions and interpret meaning in a complex social situation.9,21 We sought to discern patterns of HIE use within and across SNFs and to refine our interpretation of the effects of drivers of informational need identified during preliminary quantitative analysis. For the latter, we first developed provisional codes to identify domains of information needs in postacute care delivery.22,23 We then applied codes to capture explicit and intuited reasons for variation in when providers experienced unmet informational needs; these drivers were identified a priori based on drivers of HIE use identified in the audit log analysis, with additional inductive coding of concepts outside the identified categories. Finally, we applied technology codes when respondents described examples of using information technology (IT) to solve identified informational problems, with separate codes for whether specific aspects of IT design or implementation enhanced or hindered the consequences of its use.

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