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The American Journal of Managed Care January 2019
The Gamification of Healthcare: Emergence of the Digital Practitioner?
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Mind the Gap: The Potential of Alternative Health Information Exchange
Jordan Everson, PhD; and Dori A. Cross, 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.

In an analysis of 1 large academic hospital adopting an information exchange portal to share transitional care information with local SNFs, we find that these tools are underused. The portal was never accessed for more than half of all patients for whom it was available, and it was used just 29% of the time in the time frame surrounding handoff. Our mixed-methods approach offered a critical, underused opportunity to understand what really drives observed variation in when and how health IT is used to support care delivery. Our findings, which identify specific factors that impede the types of use that could meaningfully improve both provider and patient experience, underscore the importance of this approach and its usefulness in future research.

Our results demonstrate that SNF portal use was driven in part by contextual factors that heightened informational needs, such as lack of familiarity with a patient or referrals from hospital units with less robust paper discharge documentation. But, surprisingly, use was less likely in contexts where real-time electronic information retrieval could offer unique value, such as caring for particularly complex patient populations or managing transitional care when handoff occurs outside of traditional business hours. This suggests that current HIE infrastructure may not be delivering the value necessary to motivate SNF providers to incorporate system use into existing workflows. Indeed, qualitative inquiry reveals that nursing and social work documentation from the hospital is critical to supporting postacute care delivery but is often unavailable or difficult to access via the portal.

Our findings also reveal that HIE use is constrained by implementation issues such as limited system access rights and vague usage guidelines for when and how the portal could be used. In the absence of strategic direction from the hospital, we observed significant variation in portal usage patterns across enabled SNFs. SNFs and hospitals need to work together to develop policies that clearly articulate what types of information retrieval and use cases are possible and clarity around when the system can be used. Forming or strengthening community collaboratives provides an ideal opportunity to engage across organizations in this type of quality improvement initiative.24 Further, additional guidance at the federal level may be required to clarify Health Insurance Portability and Accountability Act concerns and ensure consistent data-sharing practices across organizations.

Hospitals and SNFs are increasingly considering electronic information sharing as a strategy to strengthen coordination and transitional care quality under payment reform.7 These findings have important implications for understanding the role that HIE-mediated information transfer can and perhaps should play in the greater context of information continuity during hospital–SNF handoffs. Current patterns of HIE use by SNFs should not be expected to drive significant improvements in care. Changing this projection requires adopting a sociotechnical perspective on improving care processes.25 Hospitals need to engage more actively with SNFs to understand information needs in this setting and organizational constraints (ie, staffing structures, workflows) that challenge care continuity. Hospitals should keep these factors in mind when adapting their technical infrastructure—for example, a more customized portal interface or summary page for postacute care providers—to make relevant information more accessible and extract value from HIE investments. Policy makers can support these efforts by requiring key nursing and social work data elements in continuity of care documentation and summary of care records generated by certified EHRs. SNFs also need to consider their structural limitations and revisit workflow design to better connect those with information retrieval capabilities to the timely needs of floor nurses with direct patient care responsibilities, as well as consider how to leverage portal access to complement existing information transfer via other means. These workflows can and should evolve as technical capabilities change.


Analyses were limited by the cross-sectional nature of the log-file data. However, we were able to leverage the explanatory sequential design of this study to further explore mechanisms underlying usage practices and explain quantitative results when tests of association were not directionally consistent with our hypotheses. Another key limitation is that data came from a single hospital and a subset of SNFs in the same local community that use 1 specific approach to HIE (a portal). This limits generalizability. However, the hospital uses a dominant commercial EHR system and has significant market power and advanced resources to support postacute transitions, suggesting that our setting represents a current best-case scenario for hospital–SNF HIE capabilities. This context enabled identification and deeper understanding of key challenges likely to be relevant to many other care settings as they explore use of electronic information sharing to support postacute transitions of care.


Electronic HIE is perceived to have great potential to facilitate information sharing that would improve postacute care transitions. Realizing these benefits requires modifications to HIE system design and information accessibility, complemented by thoughtful restructuring of enabling organizational workflows in the SNF setting. This could be facilitated by community-based hospital–SNF collaboration mechanisms and active policy efforts to promote care transition processes that more explicitly incorporate data elements specific to the needs of SNF providers.

Author Affiliations: Division of Health Policy and Management, University of Minnesota School of Public Health (DAC), Minneapolis, MN; Department of Health Policy and Management, University of Michigan School of Public Health (JSM), Ann Arbor, MI; Department of Medicine, University of California, San Francisco (JA-M), San Francisco, CA.

Source of Funding: None.

Author Disclosures: Dr Adler-Milstein is principal investigator of a grant from Hartford Foundation on the related topic of hospital–skilled nursing facility information sharing. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (DAC, JSM, JA-M); acquisition of data (DAC); analysis and interpretation of data (DAC, JSM, JA-M); drafting of the manuscript (DAC, JSM, JA-M); critical revision of the manuscript for important intellectual content (DAC); statistical analysis (DAC); and supervision (JSM, JA-M).

Address Correspondence to: Dori A. Cross, PhD, Division of Health Policy and Management, University of Minnesota School of Public Health, 420 Delaware St SE, MMC 729, Minneapolis, MN 55455. Email:

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