Leadership Perspectives on Implementing Health Information Exchange: Qualitative Study in a Tertiary Veterans Affairs Medical Center

Effect of Health Information Exchange Plus a Care Transitions Intervention on Post-Hospital Outcomes Among VA Primary Care Patients: a Randomized Clinical Trial

BACKGROUND

Health information exchange (HIE) notifications when patients experience cross-system acute care encounters offer an opportunity to provide timely transitions interventions to improve care across systems.

OBJECTIVE

To compare HIE notification followed by a post-hospital care transitions intervention (CTI) with HIE notification alone.

DESIGN

Cluster-randomized controlled trial with group assignment by primary care team.

PATIENTS

Veterans 65 or older who received primary care at 2 VA facilities who consented to HIE and had a non-VA hospital admission or emergency department visit between 2016 and 2019.

INTERVENTIONS

For all subjects, real-time HIE notification of the non-VA acute care encounter was sent to the VA primary care provider. Subjects assigned to HIE plus CTI received home visits and telephone calls from a VA social worker for 30 days after arrival home, focused on patient activation, medication and condition knowledge, patient-centered record-keeping, and follow-up.

MEASURES

Primary outcome: 90-day hospital admission or readmission.

SECONDARY OUTCOMES

emergency department visits, timely VA primary care team telephone and in-person follow-up, patients' understanding of their condition(s) and medication(s) using the Care Transitions Measure, and high-risk medication discrepancies.

KEY RESULTS

A total of 347 non-VA acute care encounters were included and assigned: 159 to HIE plus CTI and 188 to HIE alone. Veterans were 76.9 years old on average, 98.5% male, 67.8% White, 17.1% Black, and 15.1% other (including Hispanic). There was no difference in 90-day hospital admission or readmission between the HIE-plus-CTI and HIE-alone groups (25.8% vs. 20.2%, respectively; risk diff 5.6%; 95% CI - 3.3 to 14.5%, p = .25). There was also no difference in secondary outcomes.

CONCLUSIONS

A care transitions intervention did not improve outcomes for veterans after a non-VA acute care encounter, as compared with HIE notification alone. Additional research is warranted to identify transitions services across systems that are implementable and could improve outcomes.

Findings from the 2022 Yearbook Section on Health Information Exchange

OBJECTIVES

To summarize the recent literature and research and present a selection of the best papers published in 2021 related to health information exchange (HIE).

METHODS

A systematic review of the literature was performed by the two section editors with the help of a medical librarian. We searched bibliographic databases for HIE-related papers using both MeSH headings and keywords in titles and abstracts. A shortlist of candidate 15 best papers was first selected by section editors before being peer-reviewed by independent external reviewers.

RESULTS

Major themes of the set of 15 articles included the issues to be addressed in building and maintaining HIEs, HIE implementation barriers and facilitators, and the outcomes of using HIEs. The outcomes of using HIE encompassed the impact on patient care and the ability of HIEs to provide a repository of data for further research.

CONCLUSIONS

The growth of HIE has followed a course very similar to the growth of electronic health records (EHRs). Initial foci of research included technical issues in the deployment, followed by research on barriers to use. Now that EHRs are more widely implemented and used, the newer research involves the use of the electronic data contained in them. Although HIEs are currently at an earlier stage of maturity and development than EHRs and most of the articles in this review focused on implementation barriers, we have seen the beginning of research on the large amount of longitudinal and diverse data that HIEs can make available. As the implementation and use of HIEs continue to increase and become more widely deployed, we can expect that research about HIE and leveraging HIEs and the data they collect, will continue to increase.

Impact of event notification services on timely follow-up and rehospitalization among primary care patients at two Veterans Affairs Medical Centers

OBJECTIVE

To examine the effectiveness of event notification service (ENS) alerts on health care delivery processes and outcomes for older adults.

MATERIALS AND METHODS

We deployed ENS alerts in 2 Veterans Affairs (VA) medical centers using regional health information exchange (HIE) networks from March 2016 to December 2019. Alerts targeted VA-based primary care teams when older patients (aged 65+ years) were hospitalized or attended emergency departments (ED) outside the VA system. We employed a concurrent cohort study to compare postdischarge outcomes between patients whose providers received ENS alerts and those that did not (usual care). Outcome measures included: timely follow-up postdischarge (actual phone call within 7 days or an in-person primary care visit within 30 days) and all-cause inpatient or ED readmission within 30 days. Generalized linear mixed models, accounting for clustering by primary care team, were used to compare outcomes between groups.

RESULTS

Compared to usual care, veterans whose primary care team received notification of non-VA acute care encounters were 4 times more likely to have phone contact within 7 days (AOR = 4.10, P < .001) and 2 times more likely to have an in-person visit within 30 days (AOR = 1.98, P = .007). There were no significant differences between groups in hospital or ED utilization within 30 days of index discharge (P = .057).

DISCUSSION

ENS was associated with increased timely follow-up following non-VA acute care events, but there was no associated change in 30-day readmission rates. Optimization of ENS processes may be required to scale use and impact across health systems.

CONCLUSION

Given the importance of ENS to the VA and other health systems, this study provides guidance for future research on ENS for improving care coordination and population outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02689076. "Regional Data Exchange to Improve Care for Veterans After Non-VA Hospitalization." Registered February 23, 2016.