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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.

Quantitative Results

Our final quantitative data set contained 5487 hospitalized patients discharged to any of the 3 HIE-enabled SNFs between June 2014 and March 2017. Summary demographic information of this population is reported in eAppendix Table 1. During this time frame, we observed 2525 patients for whom there was corresponding HIE use in the defined 16-day broad window, representing an overall access rate of 46.0% (range, 37.6%-49.8%) (Table 1). Two SNFs experienced increased rates of system use over time, whereas the third saw usage drop. The access rate during the transition window was 28.9% (range, 9.3%-43.9%). The average “time to first look” for patients in SNF A was 7.4 days post hospital discharge (well beyond the window of handoff), compared with SNF B (0.7 days post discharge) and SNF C (2.2 days post discharge). A significant amount of transition window use occurred prior to the patient leaving the hospital, ranging from 54% in SNF C to 85% in SNF B.

Bivariate results are reported in eAppendix Table 2. In our multivariate analyses (Table 2), predicting any portal use in the broad window, the portal was less likely to be used for more complex patients, contradicting our hypothesis. Both a longer length of index hospitalization and greater number of active diagnoses on the problem list were associated with reduced likelihood of HIE use (–0.4% per day of hospitalization; –0.3% per additional diagnosis; both P <.001).

Supporting our hypothesis, patients were more likely to have associated HIE use when they were new rather than returning SNF patients (3.8%; P = .001) and when the SNF stay was preceded by an ED or observational stay rather than inpatient hospitalization (6.8%; P = .027). Our findings regarding night and weekend discharges were contrary to our expectations. Patients discharged on a weekend were less likely to have HIE used for their care (–4.3%; P = .036); nighttime discharges were associated with 4.7% lower likelihood of HIE use but with only marginal significance (P = .09).

Similar patterns held for the relationships between patient/encounter characteristics and HIE portal use during the transition window. Greater case complexity was associated with reduced likelihood of portal use (–0.5% per extra day of hospitalization; –0.5% per additional medication class; both P <.001). Being a new SNF resident no longer had a significant association. An ED or observational stay was associated with an increased likelihood of transition window portal use (11.9%; P <.001), and a weekend discharge was associated with reduced likelihood of transition window portal use (–10.7%; P <.001); transition window HIE use was not associated with nighttime discharge.

Qualitative Results

We spoke with a total of 16 respondents (Table 3). Hospital respondents included an attending hospitalist physician, the director of the hospital case management and discharge planning team, and a hospital-employed care manager embedded at a local SNF. SNF respondents included a mix of facility administrators (n = 4), admissions staff (n = 4), directors of nursing (n = 3), and floor nursing staff (n = 2). Participating SNFs ranged in size, ownership, and complexity of populations served. Respondents characterized hospital–SNF handoffs as a complex set of workflows, with administrators, admissions staff, and floor nurses working together to cull necessary patient information from different information sources. SNFs discussed adoption and use of the portal within this context of information gathering already occurring via the paper discharge summary, phone calls with hospital nursing staff, and direct patient assessment upon transfer. SNF staff received no training and little instruction regarding how the portal could or should be used to complement these other processes, leading to significant variation in how the portal was used, users’ experiences with the portal, and users’ perceptions of utility.

Portal users in SNF A were primarily billing staff, using the system to retrieve patient information for Medicare and other payers’ documentation requirements. SNF B used the portal primarily to facilitate information gathering about a patient prior to the patient being discharged into SNF care. The core portal users at this facility were nurse liaisons employed by the SNF who worked in the hospital to engage with patients, family members, and hospital providers prior to transfer. SNF C also tended to access patients’ information prior to or immediately after physical arrival, but this use was driven by the nurse managers and director of nursing to get a head start on preparing appropriate resources (eg, tube-feeding recipes, oxygen, isolation authorizations) to accommodate patient needs. Finally, SNF D—for which we did not have audit log files that captured system use—reported use of the portal to retrieve complexity/risk scores for every admitted patient. The director of nursing described use as part of a systematized process for establishing patient care plans and appropriate level of services. Importantly, SNF D perceived use of the portal prior to SNF admission as a privacy violation and accessed information via the portal only after the patient physically entered the facility.

We also gained insights into the mechanisms underlying observed associations between hypothesized drivers of informational need (from our quantitative results) and HIE use to support transitional care:

(1) Patient complexity. SNF respondents felt that increased complexity was associated with greater uncertainty regarding care needs and prompted greater HIE use. In particular, respondents used the portal to seek out more detailed information on social history and needs for complex patients. At the time of receiving a patient post discharge, SNF respondents reported that information elements related to a patient’s social determinants—such as nature of family support or food and housing security, as well as behavioral risk factors—were rarely made available in the paper discharge documentation. However, this information was also not accessible through the portal. The hospital case manager confirmed that this information would typically be housed within social work documentation and nursing notes, but these areas of the hospital EHR are restricted from portal view.

When we shared our findings that medical complexity was associated with lower HIE use, respondents noted that more difficult-to-treat patients tended to have more intensive involvement in their care from the on-site subacute physician team members, who were employed by the hospital. The presence of these physicians in the SNF created a parallel pathway into the hospital’s records, because these doctors completed their charting via full, direct access into the hospital’s EHR. Thus, SNF nurses noted that they often—especially for a more complex patient—would ask an on-site doctor or advanced care practitioner to make record inquiries on their behalf.

(2) Patient familiarity. SNF respondents largely did not perceive differences in informational needs for new versus returning patients, at least in addressing care needs stemming from the most recent hospitalization. HIE was, however, reportedly often used to gain better access to longitudinal records of patient care, such as to identify a history of falls and fractures. Access to this information was more critical for new patients, although not always time sensitive in the context of handoff. These anecdotes help to explain our quantitative finding that being a new patient at a SNF is positively associated with overall HIE use but not use during the transition window.

(3) Inadequacy of other information transfer mechanisms. Hospital respondents described paper discharge summaries as fairly consistent (due to embedded EHR modules) across providers and units but with significant variation in the timing of when this final discharge process was completed. SNF respondents were acutely aware of this issue. SNFs described challenges with patients’ discharge summaries and instructions sometimes arriving 6 to 24 hours post transfer and experiencing greater need to use the HIE portal in these scenarios. These delays were perceived by SNFs to be caused by backups and workflow hiccups at the hospital. Respondents thought it plausible but could not confirm whether these issues were more likely when patients had been discharged to their facility from the ED or an observation bed (rather than inpatient units, a finding from our quantitative analyses).

(4) Weekend discharges. Portal use was greatly restricted on evenings and weekends when administrators and senior nursing staff—the only SNF staff with portal access rights—were not on site. Whereas we hypothesized that reduced staffing at both the hospital and SNF would drive up need for HIE to fill in informational gaps during these times, key organizational constraints (staffing models, management structure, and existing workflows) prevented portal use in this context.

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