The Use of Health Information Exchange to Augment Patient ...

The Use of Health Information Exchange to AugmentPatient Handoff in Long-Term Care: A SystematicReviewClemens Scott Kruse1 Gabriella Marquez1 Daniel Nelson1 Olivia Palomares1

1School of Health Administration, Texas State University, San Marcos,Texas, United States

Appl Clin Inform 2018;9:752–771.

Address for correspondence Clemens Scott Kruse, PhD, MHA, MSIT,MBA, FACHE, School of Health Administration, Texas State University,CHP Room 2050A, 601 University Drive, San Marcos, TX 78666,United States (e-mail: [email protected]).

Keywords

► health informationexchanges

► clinical data► older patients► information

technology► communications

Abstract Background Legislation aimed at increasing the use of a health information exchange(HIE) in healthcare has excluded long-term care facilities, resulting in a vulnerablepatient population that can benefit from the improvement of communication andreduction of waste.Objective The purpose of this review is to provide a framework for future research byidentifying themes in the long-term care information technology sector that couldfunction to enable the adoption and use of HIE mechanisms for patient handoffbetween long-term care facilities and other levels of care to increase communicationbetween providers, shorten length of stay, reduce 60-day readmissions, and increasepatient safety.Methods The authors conducted a systematic search of literature through CINAHL,PubMed, and Discovery Services for Texas A&M University Libraries. Search terms usedwere (“health information exchange”OR “healthcare information exchange”OR “HIE”)AND (“long term care” OR “long-term care” OR “nursing home” OR “nursing facility”OR “skilled nursing facility” OR “SNF” OR “residential care” OR “assisted living”).Articles were eligible for selection if they were published between 2010 and 2017,published in English, and published in academic journals. All articles were reviewed byall reviewers and literature not relevant to the research objective was excluded.Results Researchers selected and reviewed 22 articles for common themes. Resultsconcluded that the largest facilitator and barrier to the adoption of HIE mechanisms isworkflow integration/augmentation and the organizational structure/culture, respec-tively. Other identified facilitator themes were enhanced communication, increasedeffectiveness of care, and patient safety. The additional barriers were missing/incompletedata, inefficiency, and market conditions.Conclusion The long-term care industry has been left out of incentives from whichthe industry could have benefited tremendously. Organizations that are not utilizinghealth information technology mechanisms, such as electronic health records andHIEs, are at a disadvantage as insurers switch to capitated forms of payment that rely onreduced waste to generate a profit.

receivedApril 22, 2018accepted after revisionJuly 29, 2018

DOI https://doi.org/10.1055/s-0038-1670651.ISSN 1869-0327.

© 2018 Georg Thieme Verlag KGStuttgart · New York

Review ArticleTHIEME

752

mailto:[email protected]

https://doi.org/10.1055/s-0038-1670651

https://doi.org/10.1055/s-0038-1670651

Background and Significance

Age is positively associated with chronic conditions and uti-lization of health resources. As 1.3 million of the population inAmerica age, the chances of them contracting one or morechronic conditions increase as do the chances of some of thementering the 16,100 nursing homes in our nation, and some ofthese conditions are best managed through an electronicinformation-based record system.1,2 As the complexity ofcare increases beyondwhat a residential or community-basedcare facility can manage, a transition of care must occur to ahigher level of care. During these transitions, communicationmust occur atmultiple levels to ensure a smooth transition forboth patient and receiving organization, smooth transfer ofrecords between organizations, maximization of outcomes,a minimizationof length of stay, and, if possible, a reductionofreadmissions to care within 30 or 60 days.3,4 Inefficienciesduring transfer can cause unnecessary rehospitalization aswell asmore complicatedmedical outcomes.4 Care transitionsare often complicated with lack of interoperability of recordsystems, high utilization at either end, and possibly thepatient’s reduced ability to participate in the communicationportion of the transition of care.

Health information exchange (HIE) is both a noun and averb: It is both the point of exchange and it also refers to theelectronic sharing of health information across organiza-tional boundaries.5 The use of electronic HIE has modifiedhow healthcare organizations view patient handoff.1HIE is asmall subset of health information technology (HIT), whichhas gained large attention over the last decade throughvarious efforts such as in the United States by its Office oftheNational Coordinator. Long-term care (LTC) organizationssuch as nursing homes, skilled nursing facilities (SNFs), andassisted living are laggards in the healthcare industry for HITadoption, and the healthcare industry has been a laggard inIT adoption compared with other industries.5 As such, thereis a gap in the literature about this important topic. Becausethe U.S. healthcare industry has been a laggard in technolo-gical adoption, legislation aimed at increasing the rate atwhich organizations make use of electronic health records(EHRs) systemswas enacted in 2009. The Health InformationTechnology for Economic and Clinical Health Act of 2009(HITECH) allocated more than $560 million for states todevelop and refine HIE capabilities within their boundaries.6

None of the incentives outlined in legislation aimed atincreasing interoperability were directed toward theapproximately 16,100 nursing homes nationwide, andalthough these organizations face substantial barriers toeven initial EHR adoption, states could have included LTCorganizations in their HIE efforts, but very few did.5

Previous research briefly examined HIE. A recent cross-sectional analysis of secondary data of all U.S. acute-carehospitals reported that of the 1,991 hospitals reportingreadmission data, 57.2% (1,139) of these facilities makesome level of effort to exchange clinical data with LTCfacilities.3 Those that reported some exchange of data withLTC facilities weremore than likely to report qualification formeaningful use (odds ratio [OR], 1.87; p ¼ 0.01 for stage 1

and OR, 2.05; p < 0.01 for stage 2).While this study analyzed1,991 organizations, it is unclear how many LTC facilitieswere involved at the other end of the exchange.

HIE can be used for fiscal reasons. Adopting HIT is part of acomplicated attempt to manage the present unsustainablecostgrowth inhealthcare.7 In addition to the cost function,HITis necessary for HIE which can play a part in patient handoffbetween levelsofcare.A lackofclearcommunicationatpatienthandoff results in increased morbidity, costs, and hospitalreadmissions.8 A barrier to HIE adoption is lack of interoper-ability, lack of funding, and lack of willingness on the part oforganizations to change.1 It is evident that there are multiplefactors pushing for an increase in the interoperability of EHRsystems: the adoption of HIT and the diffusion of HIE.

HIE can be used for safety reasons. The increase ofnosocomial infections and readmissions at patient handoffhas plagued organizations as ill, and even immunocompro-mised individuals are transferred between organizations.Health information exchanges have emerged as an informa-tion-based approach that increases the amount of informa-tion transferred at patient handoff.9 Medicare no longerreimburses organizations for unplanned readmissionswithin 30 days for patients with acute myocardial infarction,congestive heart failure, or pneumonia.10 This creates anurgent need for organizations to manage information effi-ciently to reduce the risk of patient readmissions at patienthandoff.9 Regardless, post-acute care providers aswell as LTCorganizations have the responsibility to ensure that thetransfer of a patient is as risk free as possible.

A gap in the literature exists. The increased use of EHRsystems serves as an impetus in the use of HIE. However,little is known about hospital-to-LTC utilization of HIE at anationwide level.8 Several organizations have taken initiativeto increase the interorganizational transfer of information toproduce successful patient handoffs. Organizations such asthe Continuum of Care Improvement Through InformationNew York have set out to engage organizations and relaypertinent data to relevant stakeholders.9 The state of NewYork has made the largest state-based investment for theimprovement of EHR and HIE systems. These improvementsserve as a part of the 2005 Healthcare Efficiency and Afford-ability Law for New Yorkers. The program has invested440 million dollars in HIT mechanisms to reduce the costof care for patients.11 There is currently not a comprehensiverecord of all mechanisms nationwide which creates a gap inthe literature. Further, some extensive research needs to beconducted across the nation to thoroughly explore the topicand publish best practices by those doing it well, particularlyfor the rest who have not implemented HIE.

The systematic literature review is the appropriatemechanism to fill this gap in the literature because it hasbeen described as “the most reliable source of evidence toguide clinical practice,” it provides a complete overview andanalysisof primary researchdirected towardoneresearchend,and it is often required as the basis of funded research.12

Systematic reviews often “include a broad range of relevantstudies that have been undertaken and provide a detailedcritical appraisal and synthesis of the individual studies.”13

Applied Clinical Informatics Vol. 9 No. 4/2018

The Use of HIE to Augment Patient Handoff in LTC Kruse et al. 753

They are “used increasingly to inform medical decision mak-ing, plan future research agendas, and establish clinical policy[;] systematic reviews may strengthen the link between bestresearch evidence and optimal health care.”14 A systematicliterature review is appropriate to set a foundation for anextensive study to establish best practices in preparation forthe doubling of the population of adults aged 65 years andolder will rapidly increase health care costs because they aremore likely to use healthcare services including long-termcare.

ObjectiveThe purpose of this systematic review is to identify the HIEmechanisms currently in place in LTC institutions as well asrecognize barriers to the adoption of a HIE that increasestransparency between organizations that transfer patientsduring care for admission into higher level of care facilities.The LTC organizations under study are nursing homes, SNFs,residential care, and assisted living. The rationale behind thissystematic review is to provide a framework for futureresearch by identifying the themes prevalent in the litera-ture. In addition, this research will attempt to define keyterms and themes for use in future research.

Methods

Protocol, Eligibility Criteria, and Information SourcesSpecific reporting and execution protocols were chosen forthis review. The review followed thePreferredReporting Items

for Systematic Reviews and Meta-Analyses (PRISMA) proto-col15 (see►Fig. 1) and itwas conductedusing techniques fromthe Assessment for Multiple Systematic Reviews (AMSTAR)standard.16 Literature gathered for this review was obtainedfrom three separate databases: Cumulative Index of Nursingand Allied Health Administration Literature (CINAHL) Com-plete, PubMed (which queries MEDLINE), and Discovery Ser-vices for Texas A&M University Libraries. The reviewerscombined key terms from the U.S. Library of Medicine’sMedical Subject Headings (MeSH) with Boolean operators inall three databases to identify articles. Criteria focused oninpatient residential care organizations and the use (or non-use) of a HIE. Analyzed literature covers a broad array ofgeographic regions as well as organizations at various levelsof meaningful use standards. Search criteria emphasized thetransition of care from acute care to a LTC organization.

Search and Study SelectionThesearch termsandapplicableBooleantermswereas follows:(“health information exchange” OR “healthcare informationexchange” OR “HIE”) AND (“long term care” OR “long-termcare” OR “nursing home” OR “nursing facility” OR “skillednursing facility” OR “SNF” OR “residential care” OR “assistedliving”). These terms were deliberately chosen by examiningthe index list in theMeSH. Search parameters included Englisharticles published from January 2010 to December 2017. Thistimeframewas selectedbecause it waspost-HITECHAct.WhilethereweremanyHIE efforts prior to HITECH, the EHRadoptionrates significantly increased afterward due to the meaningful-

Fig. 1 PRISMA checklist.


The Use of HIE to Augment Patient Handoff in LTC Kruse et al.754

use incentives. Organizations with EHRs exchange clinical datathrough HIE two and a half times more than their non-EHRcounterparts.5 Therefore, it was imperative to observe HIEactivity during this catalyst stage of EHR adoption. ►Fig. 2

demonstrates the literature review search process that showsthe inclusive and exclusion criteria.

The initial search resulted in 210 articles. We filtered thesearch for the last 7 years as well as full-text, English-only,and academic journals (to maintain quality of results). Thisremoved all but 39 results. These 39 results were entered onpiloted forms for consistency of review. Using a techniquefrom AMSTAR, we assigned abstracts of these 39 articles toall group members in way that ensured each abstract wasassessed for its germane nature by at least two reviewers.This process removed an additional 14 articles. Our finalgroup for analysis was 22 articles.

Data Collection Process and Data ItemsThe authors reviewed each article in the samemanner as theabstracts and determined the barriers and facilitators for theuse of HIE to augment patient handoff in LTC. Piloted formsextracted similar data from each article: authors, year ofpublication, journal, country of publication, sample size,study design, signs of bias, limitations of study, facilitatorsfor adoption, barriers to adoption, and a column for generalcomments. Facilitators were defined as characteristics orenvironmental factors that enabled the adoption and use ofHIE between LTC and other levels of care. Barriers weredefined as characteristics or environmental factors thatserves as an obstacle or impediment to the adoption oruse of HIE between LTC and other levels of care. Thereviewers also examined potential bias and limitations ofeach article. Reviewers once again held a consensus meeting

to discuss and compile observations as well as resolve anydifferences in observation.

Risk of Bias in Individual Studies and Across StudiesReviewers recorded observed bias and potential limitationsfor each article analyzed as well as across all articles. Theseobservations were recorded on the literature matrix alongwith the rest of the analysis. All results were recorded on acommon table and compiled for discussion. ►Appendix A

details bias and limitations of studies.

Synthesis of Results and Additional AnalysisThe final consensus meeting consisted of overall discussion ofobservations and inferences. Once all observations were com-piledamongall reviewers, narrativeanalysisand sensemakingwere conducted to combine similar terms;17 for example, oneset of observations was “workflow integration” and anotherwas “workflowaugmentation.”Becausebothhad to dowithanaction on workflows, we combined these into one theme.“Organizational structure” and “organizational culture” werealso similar because they were both attributes of organiza-tions. “Missing data” and “incomplete data” both describeddeficiencies of data, so they were combined. Finally, “privacy”and “security” were combined because these are often com-bined when discussing patient information. Based on thethemes in the narrative analysis, affinity tables were createdto synthesize themes for discussion.

Results

Study SelectionOur literature search narrowed 210 results down to 22 byassessingeach for suitability to our research objective.2–9,18–30

Fig. 2 Search criteria with inclusive and exclusion criteria.



We excluded 16 results because they were outside our targetdate range of 2010 to 2017. Another 157 resultswere excludedwhen we used the filters of English-only, full-text, and aca-demic journals. The abstractsof the remaining 40articleswereassessed for suitability by multiple reviewers which reducedthefinal group to 22. A kappa statistic was calculated to assessthe similarity in selection by reviewers.31 It calculated to 0.99,which is near-perfect agreement.32 See ►Fig. 2 for the selec-tionprocess. See►Appendix A for detailed calculations of thekappa statistic.

Study CharacteristicsFrom each study, reviewers extracted observations of facil-itators, barriers, potential bias, and limitations. These aresummarized in ►Table 1. We sorted the group of articles bydate,most recent to oldest. Therewere three from 2017,2,3,19

three from 2016,4,20,21 six from 2015,5,18,22–24 five from2014,5,9,26–28 three from 2013,7,8,29 one from 2012,30 andone from 2011.11

Risk of Bias within StudiesThe biases observed within studies were selection bias,3,27

workplace bias,2 self-report bias,4,26,30 data collectionbias,5,9 cognitive bias,8 and nonresponse bias.8 The biasobserved did not appear strong enough to discount any ofthe articles in the group for analysis.

Results of Individual StudiesArticles analyzed identified a variety of facilitators andbarriers, but common themes could be traced through thegroup. A detailed list of all observations and how they line upwith themes can be seen in ►Appendix B. Facilitators areillustrated in ►Table 2. The asterisk (�) by the referencenumber indicates that the theme occurred within thearticle multiple times.

About 33%of the facilitatorswere capturedwith six themes.The themesorganizational structure/culture3,4,18,21,25,28,29wasobserved seven times. These articles expressed issues such asthe organization characteristics such as bed size, location,ownership, office or hospital based, system affiliation, or aflexible organization culture that enabled HIE. Accountablecareorganization incentivestructuresalsoenableHIEwithLTC.The themeworkflow integration/augmentation6,19�,21,27,28wasobserved six times out of 39 occurrences. These articlesdescribed various aspects of workflow integration and oraugmentation. External data are effective only if it can be

integrated into the clinical workflow.33When an organizationdesigns a workflow, it must take a human-systems approach,which is to say that thehuman is theembeddedcomponentofasystem that supports people through a recognition of humancapabilities, limitations, and performance needs. When thesystem is designed this way, outcomes are improved forpatient, provider, and organization.34 Some observed thatadoption of HIE for patient transfer integrated with theirexisting workflows, and they observed that an organizationwith a supportive culture was conducive to a successfulimplementation. The asterisk (�) next to the reference numberindicates that more than one facilitator was observed for thattheme in the same article. For instance, one article pointed outthat HIE integrated nicelywith their existing workflows, and itimprovedor augmented their workflows aswell. Thiswas seenin both their billing cycle and their documentation.19 Fasterbilling was observed multiple times and was captured underthe same theme.6 Articles described policy initiatives thatincentivized better coordination of transfer and promotedinformation sharing.6,21A receptive and supportive leadershipthat supports IT acceptance is influenced by performanceexpectancy, effort expectancy, social influence, and voluntari-ness.12,18 LTC facilities pointed out that HIE was necessary tocreate continuity-of-care documentation that was greatlyappreciated by the receiving organizations.25 It was also notedthat nonprofit organizations were more likely to adopt HIEthan their for-profit counterparts.29

HIE is attributed to improving the effectiveness ofcare.2,19,22,24,27 Five articles discussed this attribute. The

Table 1 Facilitators and barriers

Facilitators Barriers

Ease of data transfer Inefficiency

Reduce healthcare costs Cost

Government funding Low usage/Adoption

Adoption of EHR is likely touse HIE

Competing organizations

Abbreviations: EHR, electronic health record; HIE, health informationexchange.

Table 2 Affinity matrix of facilitator themes in the literature

Facilitators

Theme References No. ofoccurrences

Organizationalstructure/culture

3,4,18,21,25,28,29 7

Workflow integra-tion/augmentation

6,19�,21,27,28 6

Increase effective-ness of care

2,19,22,24,27 5

Enhancecommunication

5,9,23,27 4

Adoption of EHR 4,5,20,28 4

Proper funding 4,7,11 3

Patient safety 25,27 2

Ease of data transfer 2,9 2

Efficiency 11,16 2

Market conditions 13,31 2

Reduce healthcarecost

10,19 2

39

Abbreviation: EHR, electronic health record.�The asterisk by the reference number indicates that the themeoccurred within the article multiple times.



use of HIEwas shown to decrease readmissions and decreaseadverse events.19,22,27 Others intimated that HIE allowedmore in-depth, long-term views into a patient’s history,particularly those with complex care.2,24 These five occur-rences represented 13% of the total occurrences observed.

Four articles mentioned that HIE improved their commu-nication both within and external to their own organiza-tion.5,9,23,27 HIE was named responsible for distributingpatient status to the entire clinical team, and because thecoordination of care involves many people, HIE has beenadopted to ease the human resources burden to this task.5,23

Enhanced communication helps fill a gap where the lack ofcommunication is a leading cause of error in healthcare.27

The United States is not the only country to encourageHIE. Inthe United Kingdom, HIE is used to enhance communicationas well.35 These four occurrences represented 10% of alloccurrences.

Adoption of the EHR2,9 was also observed four times,representing another 10% of the total observations. Thisobservation noted that the adoption of HIE has been easieralong with the adoption of the EHR. HIE was attributed forsafer transitions of care, which is where errorsmost occur. Ofprivate practices that responded to one survey, 15% of themwere actively sharing informationwith LTC.27 Proper fundingwas mentioned three times in the literature4,7,11 represent-ing 8% of all occurrences.

The last five themes were each mentioned twice in theliterature, accounting for 25% of all occurrences. Patientsafety25,27 was mentioned because organizations liked thereduction of duplicate testing, because a reduction in dupli-cation increased communication, which may lead to fewermedical errors, and improved patient outcomes. The otherswere ease of data transfer,2,9 efficiency,11,16 market condi-tions,13,31 and reduce healthcare cost.10,19 The proper fundingtheme spoke of the cost of both EHR and HIE capabilities;some of these organizations were included in state efforts ofHIE, and therefore they were able to afford the capability.Articles that highlighted the theme of ease of data transferspoke of their perception that exchanging clinical datathrough HIE is easier than through fax or courier. Issues ofefficiency were similar to issues of workflow, but they didnot expressly use this term. We could have combined theseinto the workflow theme. The theme of market conditionsspoke of concerns that resources spent on HIE were neces-sary because other organizations in their market were usingHIE, and therefore to compete, they felt obligated to invest inthe capability. Finally, the theme of reduce healthcare costreferred to the ongoing efforts to reduce the cost of care.Many organizations feel that a continued investment in ITwill only increase the cost of care rather than realizing thecost saving and patient safety effects of HIE by preventingduplicate test, improving communication, saving time, andimproving outcomes. The articles highlighted in this grouprealized the latter.

Five themes represented approximately 81% of all occur-rences (39/48) of barriers. These are illustrated in ►Table 3.The asterisk (�) by the reference number indicates that thetheme occurred within the article multiple times.

Cost was identified as the second most often mentioned:10 out of 44 occurrences or 23%.5�,4,6,7,11,19,25,26 Thesearticles pointed out the lack of incentives such as the mean-ingful use program5,19,25 or state and local funding.7,11

Others pointed out that LTC organizations often do nothave the budget for either the acquisition or upkeep coststhat are required for such an IT implementation.4,5

Organizational structure was observed in 9 of the 44occurrences (20%).2,4,5,9,18,21,22,26� We did combine organiza-tional culture issues along with organizational structure. Theorganizations that were the subjects of these articles were notconducive to change or they did not embrace the new tech-nology of HIE, which are cultural issues. Some articles high-lighted that their organizations were not suited for even anEHR and the high turnover in LTC organizations is not con-ducive to an IT implementation like the adoption of HIE.21Onearticle stated that the largest barrier to the adoptionofHIEwasa necessary cultural change.22 Another mentioned that it didnot have sufficient stakeholder buy-in.9

The next barrier mentioned most often was the missing,incomplete, or inaccurate data associated withHIE.2,3,23,24,27,30 This was found in 6 of the 44 occurrences,or 14%. These articles pointed out the importance of thecorrect billing codes for prompt reimbursement, and if thedata are not accurate or complete in the transfer, then a delayor penalty will follow, and that comorbidities can complicatethe codes.23 One article mentioned that unique EHR systemsthat are not interoperable create data silos because theycannot share information.24

Six articles pointed out a perception of inefficiencies thatHIE would cause their organization.2,4,8,9,19,26 These articlesdiscussed a misalignment of workflows,9,26 a communication

Table 3 Affinity matrix of barrier themes in the literature

Barriers

Theme References Occurrences

Cost 5*,4,6,7,11,19,25,26 10

Organizationalstructure/culture

2,4,5,9,18,21,22,26* 9

Missing/incom-plete data

2,3,23,24,27,30 6

Inefficiency 2,4,8,9,19,26 6

Marketconditions

26*,28 4

Lack of datastandards

5,24,26 3

Privacy and/orsecurity

26,29 2

Lack of training 6,8 2

Legalenvironment

26,29 2

44

�The asterisk by the reference number indicates that the themeoccurred within the article multiple times.



barrier,5,8,19 and overburdened staff which would serve asbarriers to their adoptionofHIE.31These represented14%ofalloccurrences of barriers listed in the literature.

The barrier ofmarket conditionswas identified four timesin the literature, representing 9% of all occurrences.26�,28

These articles expressed concern about the technologicalmaturity on HIE, and the level of both vendor and health planparticipation in HIE. They felt that there was insufficientsaturation of HIE in their market to compel them toward thetechnology.

The other four themes appeared in the literature 20% ofwhat was analyzed. These themes were lack of data stan-dards,5,24,26which refers to over 300 vendors of EHRs and noone common national solution to sharing data; privacy/security concerns,26,29 which highlighted the constant fearthat some organizations can operate with in regard to thesecurity of clinical data and potential fines from both stateand federal government; lack of training,6,8 which refers toconstant change of technology and how the training for thesechanges is often the responsibility of the organization; andlegal environment,26,29 which parallels the issue of privacy/security concerns because often part of the remedy for databreach is credit monitoring and other monetary damagesand time in court.

Additional Analysis►Tables 2 and 3 illustrate the identified themes throughoutthe literature for both facilitators and barriers to the adop-tion of HIE to support patient handoff between levels of care.We also evaluated these themes in terms of internal versusexternal factors, as depicted in ►Tables 4 and 5. Thesethemes are listed in the same order as previously listed:most oftenmentioned to least oftenmentioned. As depicted,the facilitators list only 2 of 11 themes (18%) as external to

the organization. That is to say, only two items listed arebeyond the control of the organization: proper funding,mentioned 7% of all occurrences, and market conditions,mentioned 5% of all occurrences. The barriers, however,show five of nine themes (55%) as external. These themeswere cost, market conditions, lack of data standards, privacy/security, and the legal environment, mentioned 21, 8, 6, 4, and2% of all occurrences, respectively.

A brief analysis of the quality of methodology and overallstudy design can be found in ►Appendix C. This appendixwas created as part of the piloted forms, but it did not addsignificant content for the review.

Discussion

Summary of EvidenceOur literature search identified 26 articles that were perti-nent to our research objective. From these 26 articles, weidentified facilitators and barriers identified in the literature.Several of the facilitators and barriers were similar; so, wecreated themes to capture the essence of the details identi-fied by the literature.We identified 11 themes for facilitatorsand 9 themes for barriers each listed 39 and 44 times,respectively.

Healthcare leaders should recognize the top facilitatorsand leverage them for future implementation. These leadershave control over a strong majority of the themes identified.Create an organizational culture that is conducive to theadoption of HIE recognizing that others have easily inte-grated it into their existing workflows. Leaders often look forways to increase communication bothwithin and external tothe organization, and several articles identified HIE as a wayto augment both. Leaders should also recognize that an HIEimplementation will take time and should emphasize bothprocess improvement and training of users before under-taking it.

Policy makers should examine the barriers identified inthis review. LTC should be included in future financial-incentive programs tohelp offset the cost of implementation.Policymakers should also help setmarket conditions that are

Table 4 Facilitator themes with internal/external association

Facilitators

Theme

Workflow integration/augmentation

Internal

Organizational structure/culture

Internal

Enhance communication Internal

Increase effectiveness ofcare

Internal

Patient safety Internal

Adoption of EHR Internal

Proper funding External

Ease of data transfer Internal

Efficiency Internal

Market conditions External

Reduce healthcare cost Internal

Abbreviation: EHR, electronic health record.

Table 5 Barrier themes with internal/external association

Barriers

Theme

Organizational structure/culture Internal

Cost External

Missing/incomplete data Internal

Inefficiency Internal

Market conditions External

Lack of data standards External

Privacy and/or security External

Lack of training Internal

Legal environment External



most conducive to HIE adoption and continue to developclear data standards that protect privacy and promote secur-ity for the industry.

The reviewed articles indicated a primarily optimisticapproach to the future implementation of HIEs in patienthandoff. A pilot study implementing a form of HIE betweenfive Oklahoma LTC facilities and their corresponding emer-gency departments indicated a decrease in the number ofreadmissions throughout the duration of the 20-monthstudy.22 This decrease correlates with the shift in the U.S.healthcare system to a patient-centered, value-basedapproach that emphasizes HIT as a tool to improve care.22

The overall health of the patient population admitted intoLTC facilities must be considered as well. Elderly patients aremore likely than the rest of the population to take multipleprescriptions, have comorbidities, and see a multitude ofproviders.22 With the multiple opportunities for error thatexist because of the health of the geriatric population,organizations and patients alike can benefit from the accu-rate transfer of information.

Nearly one in four individuals in the United States suffersfrom multiple conditions, while one-half of the populationsuffers from a chronic condition. The percentage of thepopulation who suffers from at least one chronic conditionincreases to 75% among older adults.5 The successful man-agement of these conditions is contingent on the collabora-tion of multiple stakeholders throughout the course ofpatient care.23 Thus, comprehensive and accurate informa-tion is required. A study of 20 clinical staff from a U.S.Midwestern long-term post-acute care facility (LTPAC) foundthat providing LTPAC staff with a more in-depth view of apatient’s condition aids the course of care beyond the acute-care setting. Medication errors such as the erroneous con-tinuation of an antibiotic can be prevented if proper infor-mation is available.5 In many countries, the LTPAC coversservices such as LTC hospitals, nursing homes, SNFs, andresidential care.36

The end goal of the accurate and efficient transfer ofinformation through an HIE must be articulated as a needfor LTC facilities. The concept for an HIE comes inmany formsand requires the cooperation of organizational stakeholders.Health information exchanges can aid in the treatment andbilling of chronic care coordination. The proper course ofaction for chronic care coordination requires open commu-nication between pertinent providers to ensure that condi-tions are properly treated.23 For now, many LTC facilities arefocused on the proper implementation of EHRs, a conceptthat the rest of the healthcare world has long since imple-mented due to the HITECH Act of 2009. LTC facilities thathave implemented EHRs utilize HIE mechanisms at a rate of2.5 times more than their non-EHR counterparts.5 Among across-sectional study across all New York State nursinghomes, most information was exchanged with pharmaciesand laboratories. The state of New York has invested aconsiderable amount of time on both research and imple-mentation of HIE mechanisms in nursing homes and theresults are encouraging and illustrate the need for initiativesto drive other organizations to invest in HIEs.5

For LTC facilities, there are barriers to the implementationof HIEs aside from the complete lack of financial incentives.The integration of software among organizations is a pro-minent issue, as well as differing information needs.5 Com-pensation for the coordination of chronic care among thegeriatric population may not suffice if the cost of generatingbilling and documentation exceeds the capitated reimburse-ment for the treatment of the condition. In this regard, HIEscan reduce unnecessary documentation and tests by improv-ing communication among providers and reducing waste.23

Healthcare insurers, including the federal and state govern-ments who pay for a majority of healthcare for older adults,must reduce waste to make a profit.

If organizations do not receive the proper and necessaryinformation, the HIE is only an expense and not a benefit. It isimperative that LTC facilities, which can most benefit fromthe smooth transfer of information, implement HIE mechan-isms to stop the unnecessary harm caused by the poortransfer of information.

LimitationsLimitations stemmed from the nature of current studies,which assess LTC implementation of EHRs and HIEs ingeneral. Because the implementation of HIT in LTC organiza-tions is low compared with other organizations, studies thatassess the true notion of patient handoff from acute care toLTC facilities or from LTC facilities to higher levels of care arelimited and premature in their scope.

While selection bias is a large threat to any study, wecontrolled for that threat by adopting techniques fromAMSTAR. We ensured multiple reviewers independentlyevaluated articles and held regular consensus meetings tokeep everyone calibrated on the purpose and scope of thisreview.

One of the filters used in the search for articles was “freetext” which eliminated seven articles from consideration.This is a limitation because the impact of those seven articleson the outcome of our systematic literature review isunknown. Additional funding would enable access to thesearticles and if findings are significantly different, a studyshould be republished.

Another limitation is that this systematic literaturereview fell short of a meta-analysis. A sufficient level oforiginal data from the studies was not collected. The sciencebehind the studies analyzed was not sufficiently robust. Ourtime was short for this round of research, so we held short atthe systematic review.

Conclusion

Health information exchanges are imperative to the future ofcare in the LTC sector. With the growth of the aging popula-tion, organizationsmust be ready to provide accurate qualitycare to ensure the well-being of patients. The benefits of anHIE cannot be underestimated, given that the elderly popu-lation presents more comorbidities and chronic conditionthan the rest of the population. Current barriers to the properimplementation of an HIE include network pitfalls and



competing stakeholder needs, as well as the financial com-ponent of implementing a useable HIE.

The status of EHR implementation in LTC facilities variesthroughout the country with HIEs lagging even furtherbehind.37 Significant research has been conducted on hospitalreadmissions from the LTC setting, but not enough researchhas been conducted on successful mechanisms to preventreadmissions.38 Future research should focus on the need toincreasefinancial incentives for LTC facilities to implementHIEmechanisms, as well as the actuarial effect of readmissions onLTC facilities as financial penalties become more stringent.This systematic review serves as a good foundation for exten-sive research to establish best practices.

Multiple Choice Questions

1. The HITECH Act applied incentives for the adoption of HITfor which of the following organizations?a. Acute-care hospitals.b. All size of physician practices.c. Long-term care.d. a and b only.Correct Answer: The correct answer is option d.

2. Which is the largest barrier to the adoption of HIT in LTCorganizations?a. Cost.b. Privacy/security.c. Organizational culture.d. Market conditions.Correct Answer: The correct answer is option a.

Protection of Human and Animal SubjectsThis study was performed in compliance with the WorldMedical Association Declaration of Helsinki on EthicalPrinciples for Medical Research Involving Human Sub-jects, andwas not reviewed by Institutional Review Boardbecause it is exempted, IAW 45CFR46.

Conflict of InterestNone.

FundingNone.

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Appendix A Kappa statistic calculation



https://www.healthit.gov/playbook/care-settings/

https://www.healthit.gov/playbook/care-settings/

Appen

dix

BTa

bleof

observations

,the

mes,b

ias,

andlim

itations

Authors

Facilitator

observations

Them

esBa

rrierob

servations

Them

esBias

Limitations

Cross

andAdler-

Milstein

3Po

licyinitiative

sha

veim

prov

edtran

sition

sbe

twee

nho

spitals

andLTCprov

idersby

ince

nti-

vizing

better

coordina

tionan

dprom

otingthead

option

ofIT

andinform

ationsharing.

Ana

-lysisof

2014

hospital

survey

data

hasindicatedthat

the

majorityof

hosp

italsroutinely

enga

gein

elec

tron

icexch

ange

Organ

izationa

lstructure/cu

lture

Self-assessmen

tsof

HIE

imple-

men

tation

may

resultin

inac-

curate

resu

lts.

Mea

suresus

edforHIE

implem

entation

vary,so

interpretationacross

boun

d-ariesisinaccu

rate

Missing

/inco

mplete

data

Self-reportda

taaresu

bjec

tto

bias

such

associal

acce

ptab

ility

Themea

sure

ofho

spital

exch

ange

was

limited

toSC

RwithLTCprov

iders,

andthere

may

have

been

othe

rtype

sof

exch

ange

.Thiswou

ldtend

toun

derstatetheap

plicab

ility

oftheresultsof

thisstud

y

Mee

hanan

dStaley

19Usage

ofHIE

inLTCsha

sshown

aredu

ctionin

read

mission

rates

dueto

less

tran

scriptionerrors

Increa

seeffec-

tive

ness

ofca

reBe

caus

eLTCsdo

notqu

alifyfor

mea

ning

fulu

seince

ntives,the

yareless

likelyto

person

ally

inve

stinto

anEH

Rsystem

oftheirow

nan

dhe

ncehe

alth

inform

ationexch

ange

Cos

tNon

eiden

tified

Stud

ylim

ited

toACOs,

soge

n-eralizab

ility

outsideof

theACO

isgrea

tlylim

ited

Faster

andmoreaccu

rate

billing

Workfl

owinte-

gration/

augm

entation

TheACO

alread

ystrugg

leswith

commun

icationwithinitsco

m-

plex

orga

nizationa

lstruc

ture;

commun

icatingou

tsidethe

orga

nizationisalargeba

rrier

Inefficien

cy

Ove

rallim

prov

edqu

alityof

docu

men

tation

andredu

ced

coststo

thepa

tien

tassociated

withdu

plicatetests/orde

rsthe

patien

tha

srece

ntlyha

ddo

nein

aprev

ious

office

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owinte-

gration/

augm

entation

Reduc

ehe

alth-

care

cost

Mee

han2

HIE

canbe

used

toex

pedite

inform

ationdu

ring

thetran

si-

tion

ofca

refrom

acuteho

spitals

totheLTC

Efficien

cyAtbe

st,acutecare

staff’sinac-

curate

completionof

theEH

RMissing

/inco

mplete

data

Workp

lace

bias:

staffinterviewed

hadacce

ssto

the

HIE

which

par-

tially

justified

theirrole

atthe

long

-term

post-

acutecare

facility

Smallsam

plesize

(n¼

20)from

onelocation

may

limitthe

external

valid

ityof

theresu

lts

Thispa

tien

tgroup

espe

cially

requ

ires

man

agem

entof

multi-

plech

ronicillne

sses

that

con-

tributeto

theirov

erallp

lanof

care

Increa

seeffec-

tive

ness

inthe

man

agem

entof

care

Resu

ltsin

aninefficien

tproc

ess

(staffmak

ingfollo

w-upph

one

calls

toclarifyon

orders,

tests)

Inefficien

cy

Thesystem

sprov

ideaseam

less

exch

ange

ofpa

tien

tda

tathat

ultimatelyim

prov

equ

alityof

care

andim

prov

eprodu

ctivity.

Man

yorga

nization

sarein

the

earlystag

esof

implem

entation

Ease

ofda

tatran

sfer

Atworst,thesega

psca

nad

verselyaffect

thepa

tien

tan

dcrea

tearead

mission

Organ

iza-

tion

alstruc-

ture/culture

Workfl

owinte-

gration/

augm

entation



Appen

dix

B(Con

tinue

d)

Authors

Facilitator

observations

Them

esBa

rrierob

servations

Them

esBias

Limitations

andarefocu

sing

onthebe

nefits

ofim

plem

entation

ofEH

Rs

Jamoo

net

al20

Thisna

tion

widestud

yby

theU.S.DHHSrepo

rtson

how

man

yprivateprac

tice

sha

veim

plem

entedEH

Rsystem

ssinc

eONCce

rtified

thesystem

sas

mee

ting

themea

ning

fulu

secriteria.T

hereportstates

15%

oftheseprac

tice

sareac

tively

sharinginform

ationwithLTCs

Ado

ptionof

EHR

None

iden

tified

Non

eiden

tified

None

iden

tified

Basedon

seco

ndaryda

ta(N

ationa

lAmbulatoryMed

ical

CareSu

rvey

)which

may

notbe

thetest

data

toan

swer

the

research

question

Towne

etal4

Thelocation

ofan

orga

nization

(rural

orurban

)was

notfoun

dto

bealim

itation,

withrural

orga

nization

sac

tually

having

high

erratesof

adop

tion

ofEH

Rsan

dHIE

tech

nology

Ado

ptionof

EHR

Increa

sing

numbe

rof

indivi-

dualsreaching

theag

ein

which

LTCisrequ

ired

puts

anad

di-

tion

alstrain

onthealread

ystrained

healthcare

system

Organ

iza-

tion

alstruc-

ture/culture

Self-reportda

tamay

besu

bjec

tto

bias

such

associal

respon

sibility

Across-sec

tion

alstud

ydo

esno

tprov

idetren

dsov

ertime.

Data

werelim

ited

tothe20

10NSR

CF

datasetan

dco

mpa

redwiththe

2012

data.D

atawerelim

ited

tothefacilitylevel,an

dtherefore

inferenc

esco

uldno

tbemad

eto

anyothe

rsize

orga

nization

.No

data

toen

able

inferenc

esto

ruralh

ealth

Rece

ptivelead

ersh

ipOrgan

izationa

lstructure(pro-

cess)/cu

lture

Ove

rburden

edstaff

Inefficien

cy

Prop

erfund

ing

Ade

quate

fund

ing

Cos

tCos

t

Alexand

eret

al21

Theresearch

team

foun

dthat

assemblingane

tworkof

prov

i-de

rsthat

expresstheun

ique

need

sof

theorga

nization

iscritical

forprop

erim

plem

enta-

tion

ofEH

Rsan

dHIEsin

anu

r-sing

homeor

long

-term

care

facility.

HIE

inco

rporated

into

existing

workfl

ows.Pa

rticipa-

tion

intheHIEbo

thin

andou

tof

thefacility

Workfl

owinte-

gration/

augm

entation

Theprope

rim

plem

entation

ofEH

Rs,a

ndmuc

hless

HIEs,

isco

ntinge

nton

successful

staff

training

Tech

suppo

rtNone

iden

tified

Thelead

ersh

ipteam

forthe

orga

nization

was

notpresen

tdu

ring

theinterviews.

One

ofthepa

rticipatingfacil-

itiesha

don

lytw

opa

rticipan

ts

Appropriate

training

and

retraining

Tech

supp

ort

Highturnov

erin

nursingho

mes

andsimila

rorga

nizations

nega

-tively

affectstheim

plemen

ta-

tion

oftheseIT

proc

esses

Organ

iza-

tion

alstruc-

ture/culture

Getting

othe

rsto

usetheHIE

Marke

tco

nditions

Getting

theHIE

operationa

lTe

chsupp

ort

(Con

tinu

ed)



Appen

dix

B(Con

tinu

ed)

Authors

Facilitatorobs

erva

tion

sTh

emes

Barrierobs

erva

tion

sTh

emes

Bias

Limitations

Puttingpo

liciesfortech

nology

inplace

Organ

izationa

lstructure/cu

lture

Filip

ova6

Quicker

billing

was

iden

tified

asafacilitator

totheim

plem

en-

tation

ofEH

Rsan

dHIE

inlong

-term

care

facilities.

Improv

ing

thespee

dof

tasksan

dfunc

tion

sisabe

nefitthat

may

serveas

anince

ntivewhe

nno

gove

rnmen

t-prov

ided

ince

ntiveex

ists

Workfl

owinte-

gration/

augmen

tation

Fina

ncialc

osts

asso

ciated

with

theim

plem

entation

ofHIEsha

slim

ited

orga

nization

s,to

the

pointthat

someorga

nization

sdo

notev

enha

vethetech

nical

capacityforpu

blic

health

repo

rtingpu

rpos

es

Cos

tNon

eiden

tified

Non

eiden

tified

Tech

supp

ort

Nursesdo

notha

vetheprope

rtraining

Lack

oftraining

Yeam

anet

al22

Theim

plem

entation

ofan

HIE

andHIT

hasresulted

ina

decrea

sein

thenu

mbe

rof

read

mission

sfollo

wingthe

stud

y.Th

issh

edslig

hton

the

true

bene

fits

ofHIE

implem

entation

Increa

seeffec-

tive

ness

ofcare

Theim

portan

ceof

anHIE

can-

notbe

overstated

inLTCorga

-nization

sbe

causepa

tien

tsha

vemuc

hhigh

erhe

althca

rene

eds

than

othe

rpo

pulations

(com

orbid

cond

itions

,tak

emultiplemed

ications

,etc.).T

hebigg

estba

rriere

xperienc

edwas

ane

cessarycu

ltural

chan

ge

Organ

iza-

tion

alstruc-

ture/culture

Non

eiden

tified

Smallsam

ple(con

venien

cesample,

n¼

5)size

brings

into

question

whe

ther

itprop

erly

represen

tsthepo

pulation.Sta-

tisticalan

alysiswas

restricted

tode

scriptiveon

ly.A

saresu

lt,

even

correlationwou

ldbe

diffi-

cultto

justify.

Onlych

iefco

mplaintswere

exam

ined

fortran

sfer

anddid

notexam

inewhe

ther

theco

m-

plaintswererelatedto

anex

isting

cond

itionor

new

cond

ition

Peters

and

Bunk

ers2

3Th

eco

ordina

tionof

chronic

care

hasbe

eniden

tified

asrequ

iringtheassistan

ceof

man

yindividua

ls.P

roviding

accu

rate

inform

ationiscritical

totheim

plem

entation

ofa

successful

HIE

Enha

nce

commun

ication

Billing

andCPT

coding

proc

e-du

resmus

tbe

prop

erly

under-

stoo

dby

theprov

ider

andthe

patien

t.Ifthisisno

tthecase,

thereportedinform

ationmay

beinco

rrec

tan

dno

tof

useto

themed

ical

bene

fitof

the

patien

t.Com

orbiditiesex

acer-

bate

thepo

ssibility

ofco

nfu-

sion

,aco

mmon

alityam

ongthe

geriatricpo

pulation

Missing

/inco

mplete

data

Not

astud

y

Hill

etal24

HIEsha

vebe

ende

mon

strated

asefficien

taids

toph

ysicians

byallowingamorein-dep

th,long

-term

view

into

thepa

tien

t’s

history

Efficien

cyCurrently,“

unique

”iden

tifiers

may

pose

issu

esiforga

nization

sov

erlaptheform

atused

asa

unique

iden

tifier

Lack

ofda

tastan

dards

Not

astud

y



Appen

dix

B(Con

tinu

ed)

Authors

Facilitatorobs

erva

tion

sTh

emes

Barrierobs

erva

tion

sTh

emes

Bias

Limitations

Increa

seeffec-

tive

ness

ofcare

Form

atsforstoringmed

ical

reco

rdscrea

tesilosthat

resist

sharing

Missing

/inco

mplete

data

Alexand

eret

al18

Research

ersim

plem

entedpro-

cess

improv

emen

tmea

suresin

age

ograph

icloca

tion

with

someof

thehigh

estratesof

30-

dread

mission

s.Th

e16

orga

ni-

zation

sin

thestud

ywere

rece

ptiveto

phased

implem

en-

tation

ofaHIE.Th

eresu

ltsof

theim

plem

entation

canbe

uti-

lized

forbe

nchm

arking

pur-

poses.

Thiswas

anim

plem

entation

stud

yan

dau

thorswerealso

part

ofthe

implem

entation

team

;the

re-

fore,therewas

apo

tentialfor

cogn

itivebias

Organ

izationa

lstructure/cu

lture

Networkpitfallsca

noc

curas

aresu

ltof

poorne

tworkplan

ning

orim

prop

eralignm

entwith

clinical

workfl

ow

Tech

supp

ort

Non

eiden

tified

Add

itiona

ltec

hnological

and

human

reso

urce

saredifficu

ltto

comeby

forev

eryorga

nization

Use

caseswerehe

lpful

Marke

tco

nditions

Everyfacilityne

eded

addition

altech

nological

andhu

man

reso

urce

sto

build

theHIE

netw

ork

Organ

iza-

tion

alstruc-

ture/culture

Hassole

tal25

Theintrod

uction

ofan

HIE

tofacilitatetheexch

ange

ofinfor-

mationne

cessaryto

crea

teco

ntinuity

ofca

redo

cumen

tswas

wellrec

eive

dam

onglong

-term

care

prov

iders

Organ

izationa

lstructure/cu

lture

ITco

nstraintsin

thelong

-term

care

setting

Tech

supp

ort

Non

eiden

tified

Only29

ofthe51

HIEs

respon

ded

,which

may

limit

gene

ralizab

ility

toallH

IEs

Theprop

erexch

ange

ofinfor-

mationwill

resu

ltin

safertran

-sitions

ofpa

tien

tsinto

thelong

-term

care

setting

Patien

tsafety

LTCorga

nization

srece

iveno

ince

ntiveforthead

option

ofHIT

initiative

s

Cos

t

Abramso

net

al5

Organ

izations

withan

EHRwere

foun

dto

be2.5times

more

likelyto

participatein

some

form

ofHIE,althou

ghthemos

tco

mmonHIE

mec

hanism

inplaceisin

correspo

nden

cewith

pharmacies

Adop

tion

ofEH

RLack

offiscal

ince

ntives

forHIT

adop

tion

Cos

tDataco

llection

bias

beca

useno

tallsurve

yswere

complete

Onlyco

nduc

tedin

New

York

City,

soex

ternal

valid

ationcan-

notbe

assured.Not

allsurve

yswereco

mpleted

,which

mad

eco

nclusion

sless

than

robu

st

(Con

tinue

d)



Appen

dix

B(Con

tinue

d)

Authors

Facilitatorobs

erva

tion

sTh

emes

Barrierob

servations

Them

esBias

Limitations

Altho

ughthereisno

fina

ncial

ince

ntivefornu

rsingho

me

adop

tion

,orga

nizations

have

adop

teddu

eto

thede

mon

-strablebe

nefits

ofim

prov

edco

mmun

ication

Enha

nce

commun

ication

Lack

ofinteroperab

ility

with

curren

tsystem

sLack

ofda

tastan

dards

Initialc

ostof

acquisition

Cos

t

Com

peting

priorities

Organ

iza-

tion

alstruc-

ture/culture

Ong

oing

cost

ofmaintaining

anEM

RCos

t

Rich

ardso

net

al9

Datatran

sfer

viaHIE

quickly

aggreg

ates

patien

treco

rdda

tafrom

variou

sHIE

source

san

ddistribu

tespa

tien

tstatus

info

totheen

tire

clinicalteam

(not

just

oneclinician)

Ease

ofda

tatran

sfer

Interorgan

izationa

lHIE

data

tran

sfer.Lack

ofco

mpe

ting

stakeh

older

buy-in

Organ

iza-

tion

alstruc-

ture/culture

Thestud

ywas

performed

within

theresearch

ers’

ownfacility,

which

couldbias

theda

taitself

NoED

physicianinterviewsto

augm

entda

taco

llection

Enha

nce

commun

ication

Misalignm

entwithclinical

workfl

owsthat

inhibiteduseof

HIE-based

patien

ttran

sfer

data

Inefficien

cy

Cam

pion

etal26

Theim

plem

entation

ofda

tash

aringam

ongorga

nization

sha

sbe

enfoun

dto

reduc

ehe

althcare

costs

Redu

cehe

alth-

care

cost

Tech

nological

maturity

Marke

tco

nditions

Self-repo

rtda

tamay

besu

bjec

tto

bias

such

associal

resp

onsibility.

Participan

tswere

notprov

ided

aclea

rde

finition

ofba

rriers

toad

op-

tion,

sotheir

resp

onsesmay

threaten

con-

struct

valid

ity

Smallsam

plesize

brings

into

questionwhe

ther

itprop

erly

represen

tsthepo

pulation.

Theda

taus

edin

thisstud

ydo

notac

tually

illus

tratethesh

ar-

ingof

patien

tda

ta

Vend

orpa

rticipation

Marke

tco

nditions

Privac

yan

dsecu

rity

Privac

yan

d/or

secu

rity

Regulatoryrequ

irem

ents

Lega

len

vironm

ent

Tech

nica

lsup

port

Tech

suppo

rt

Organ

izationa

lstruc

ture

Organ

iza-

tion

alstruc-

ture/culture

Workfl

owintegration

Inefficien

cy

Datastan

dards

Lack

ofda

tastan

dards

Prov

ider

attitude

sOrgan

iza-

tion

alstruc-

ture/culture

Fina

ncialresou

rces

Cos

t

Hea

lthplan

participation

Marke

tco

nditions



Appen

dix

B(Con

tinue

d)

Authors

Facilitatorob

servations

Them

esBarrier

obs

erva

tion

sTh

emes

Bias

Limitations

Lyng

stad

and

Hellesø

27Lack

ofco

mmun

icationisa

lead

ingcaus

eof

errorin

healthca

re

Enha

nce

commun

ication

Onc

eim

plem

ented,

adistinct

limitationremains

that

EHRs

containretrospe

ctivepa

tien

tda

taan

dcaregive

rsne

edsys-

temsformea

nsof

prospe

ctive

commun

icationab

outthe

patien

t

Missing

/inco

mplete

data

Selectionbias

lean

edtoward

moreex

peri-

ence

dworke

rs,

soex

ternal

valid

-ityislim

ited

Onlyex

amined

Norw

egian

orga

nization

s

Dec

reasead

verseev

ents

Increa

seeffec-

tive

ness

ofcare

Save

time

Workfl

owinte-

gration/

augmen

tation

Patien

tsafety

Patien

tsafety

Wan

get

al28

Hospital-b

ased

LTCsan

d/or

nursingho

mes

have

agrea

ter

likelihoo

dof

adop

ting

EHRsys-

temsinto

theirprac

tice

(espe-

cially

ifin

aruralloc

ation)

Ado

ptionof

EHR

Organ

izationa

lbarriersto

EHR

system

sin

LTCsinclud

enu

mbe

rof

beds

,urba

nor

real

loca

tion

,ho

spital-based

orfree

stan

ding

,an

dfor-profi

tor

nonp

rofit

Marke

tco

nditions

Non

eiden

tified

Thereisno

unan

imou

sag

ree-

men

ton

mea

suring

HIT

adop

tion

Ultim

atelythiswill

increa

seprod

uctivity

amon

gstaffan

dprov

iders

Workfl

owinte-

gration/

augmen

tation

ITacce

ptan

ceisinflue

nced

bype

rforman

ceex

pectan

cy,e

ffort

expe

ctan

cy,s

ocialinfl

uenc

e,an

dvo

luntariness

Organ

izationa

lstructure/cu

lture

MacTa

ggartan

dTh

orpe

7Th

erepo

rtsu

mmarizes

how

LTCsca

nfacilitatepa

tien

tca

reus

ingcu

rren

ttech

nologiesan

dprov

ides

mea

suresforsuccess

utilizing

gove

rnmen

tresource

san

dtheirem

ploy

ees

Prope

rfund

ing

Fund

ingco

ntinue

sto

serveas

themainprob

lem

inim

ple-

men

ting

HIT

toolsat

LTCs

Cos

tNot

astud

y

Kessleret

al8

Thisve

ryco

mpreh

ensive

review

ofov

er20

0articles

onthe

elde

rlypa

tien

ts’trans

itionfrom

nursingho

mes

totheED

give

sa

fairly

accu

rate

portrayalo

fcu

r-rent

issu

esan

dalso

prov

ides

somereco

mmen

dations

asso

lution

s

Non

eiden

tified

Thearticlereinforces

theco

m-

mon

them

ethat

aprim

aryba

r-rier

oftrea

ting

theelde

rlyisa

lack

ofco

mmun

icationbe

twee

nallfacilities

Inefficien

cyCog

nitive

bias

andbe

havioral

bias

None

iden

tified

Lack

oftraining

Lack

oftraining

Ham

annan

dBe

zborua

h29

Ana

lysisof

anorga

nization

’stax

status

prov

ides

insigh

ton

HIE

userates,

aswella

sratesof

implem

entation

ofIT

mec

han-

isms.

Nonp

rofitorga

nization

s

Organ

izationa

lstructure/cu

lture

Privac

yreason

scanfunc

tion

toreduc

ethelikelihoo

dof

statis-

tically

sign

ificant

resu

lts

Privac

yan

d/or

secu

rity

Non

eiden

tified

Limited

samplealso

limitsthe

external

valid

ity

(Con

tinue

d)



Appen

dix

B(Con

tinue

d)

Authors

Facilitator

observations

Them

esBa

rrierob

servations

Them

esBias

Limitations

areshownto

bemorelikelyto

utilize

EHRsthan

theirfor-profit

coun

terparts

Regu

latory

requiremen

tsalso

func

tion

differen

tlyon

astate-

to-state

basisan

dca

nskew

the

continuity

ofresu

lts

Lega

len

vironm

ent

Wolfet

al30

Organ

izations

left

outof

adop

-tion

ince

ntives

requ

irethe

grea

test

assistan

cein

the

adop

tion

oftech

nology

and

demon

strate

atrem

endou

sne

edforIT

dueto

thepo

pula-

tion

need

s

Tech

supp

ort

Current

survey

question

suti-

lized

dono

tprope

rlyassess

the

need

ofEH

Rsin

LTCfacilities.

Survey

question

ssh

ould

bemodified

toaccu

rately

depict

thene

ed

Missing

/inco

mplete

data

Nonrespo

nsebias

from

ineligible

hospitals(cou

n-teredby

weigh

t-ing).

Self-repo

rtda

tamay

besu

bjec

tto

bias

such

asso

cial

respon

sibility

Seco

ndaryda

tawereus

edwhich

may

notprope

rlyad

dress

theresearch

question

Kern

etal11

Allfacilitiestheau

thorsreache

dou

tto

participated

inthesur-

vey.

Also,

they

allrec

eive

dthe

sametype

ofstatefund

ing

towardEH

Rim

plem

entation

(HEA

L1gran

tees).Th

estud

yassessed

facilitiesba

sedin

New

York,w

here

thereisthelargest

state-based

inve

stmen

t(nationw

ide)

ofEH

Rsan

dHIE

system

s.New

York

canserveas

amod

elan

dthestud

yha

sna

tiona

limplications

asthe

coun

tryismov

ingtowardco

n-tinu

edinve

stmen

tin

HIT

infrastruc

ture

Prope

rfund

ing

Thesamplesize

(26)

isamajor

limitation,

andtheresultswere

ofbo

rderlin

estatisticalsignifi-

canc

e.Th

estud

yalso

question

son

lyon

etype

ofgran

trec

ipient,

althoug

hthestateha

svariou

sHIEgran

ts.T

heresultsmay

vary

ifthestud

yisread

ministered

withallo

ftheHEA

Lprogram

gran

tees

Cos

tNone

iden

tified

Smallsam

plesize

andresu

lts

that

werebo

rderlin

esignificant.

Thelatter

was

helped

bylarge

effect

sizes.

Onlyon

esource

offund

ingwas

exam

ined

.Th

isstud

yco

llected

observa-

tion

son

lyafter1y:

Long

ertimes

arene

cessaryto

iden

tify

sustaina

bility

Abbrev

iations

:ACO,a

ccou

ntab

lecare

orga

nization

;ED

,em

erge

ncyde

partmen

t;EH

R,elec

tron

iche

alth

reco

rd;HIE,he

alth

inform

ationexch

ange;

HIT,he

alth

inform

ationtech

nology

;LTC,long

-term

care.



Appen

dix

CDetailo

fstud

yde

sign

,qua

lity,

care

setting,an

dcritique

ofstud

y

Authors

Studydesign

0¼

Qua

litative

1¼

Qua

ntitative

2¼

Mixed

3¼

Review

4¼

Other

Qua

lity

Critiqu

eof

study

Caresetting

Cross

and

Adler-

Milstein

3

Cross-sec

tion

al,q

uantitative

stud

y;seco

ndaryda

taan

alysis

1High-qu

ality,

largesample

(n¼

1,99

1)Con

foun

ders

notco

nsidered

for

effectsattributed

toHIE.Num

-be

rof

LTCfacilitiesat

theothe

ren

dof

HIE

commun

icationno

tiden

tified

.Reg

ionof

coun

tryno

tiden

tified

Hospitalsan

dlong

-term

care

facilities

Mee

hanan

dStaley

19Re

view

2Mode

rate-qua

lityreview

ofsev-

eral

good

-qua

litystud

ies

(N¼

11)

Narrow

focu

sof

thestud

ymak

esitsco

nclusions

difficu

ltto

use

outsideACOs.

Stud

ylim

ited

toACOs,so

gene

ralizab

ility

outside

oftheACO

isgrea

tlylim

ited

Outpatient

Mee

han2

Qua

litative,

interview-based

stud

y0

Mode

rate-qua

lity,

smallsam

ple

size

forsocial

scienc

es(n

¼20

)Werestaffm

embe

rsinterviewed

therigh

tpe

ople

tokn

ow?Were

confou

ndingfactorsprop

erly

cons

idered

foreffectsqu

eried

abou

t?ACOsmay

notbe

old

enoug

hto

really

know

prope

rcaus

ean

deffect

relations

hips

Long

-term

post-acu

tecare

Jamoo

net

al20

Databrief

4High-qu

alityda

tabriefsummar-

izingEH

Rad

option

ratesna

tion-

wide20

13to

2014

Non

eoffice

-based

care

Towne

etal4

Cross-sec

tion

al,q

uantitative,

usingseco

ndaryda

ta1

High-qu

ality,

largesample

(n¼

2,30

2).

Self-reportda

tawereno

tfol-

lowed

upwithteleph

one

calls

orem

ailsto

questionor

extend

the

data

Reside

ntial-carefacilities

Alexand

eret

al21

Qua

litative,

interview-based

stud

y0

Mode

rate-qua

lity,

smallsam

ple

forsocial

scienc

es(n

¼15

)of

nursingho

melead

ers

Limited

scop

eof

stud

yprev

ents

applying

resu

ltsex

ternal

tothe

smalln

umbe

rof

orga

nization

sinterviewed

.Lev

elof

expe

rien

ceof

thelead

ersinterviewed

was

notno

rmalized

forco

mparison

Nursing

homes

Filip

ova6

Qua

litative,

interview-based

stud

y0

High-qu

alitystud

y,go

odsample

size

(n¼

156)

aCofou

ndingfactorsforfind

ings

notex

plored

skilled

nursingfacilities

Yeam

anet

al22

Retrospec

tive,q

uantitative

design

1Marginalqu

alitywithave

rysm

all

sampleforsocial

scienc

es(n

¼5)

Con

foun

ding

factor

ofread

mis-

sion

ratesde

crea

sing

across

the

nation

was

note

xplored.

Was

the

Long

-term

care

andac

ute-care

settings

(Con

tinue

d)



Appen

dix

C(Con

tinue

d)

Authors

Studydesign

0¼

Qualitative

1¼

Quan

titative

2¼

Mixed

3¼

Review

4¼

Other

Qua

lity

Critiqu

eof

stud

yCaresetting

effect

repo

rted

attributab

leto

theus

eof

HIE

orto

natural

nation

altren

d?Th

eresearch

ers

notedthat

itisdo

ubtfulthat

their

find

ings

couldbe

duplicated

,which

shed

sdo

ubton

thescien-

tificna

ture

ofthisstud

y

Peters

and

Bunk

ers2

3Ed

itorial

4N/A

Chroniccare

man

agem

ent,

office

-based

andho

me-ba

sed

care

Hill

etal24

Editorial

4N/A

Hospital-b

ased

,office

-based

Alexand

eret

al18

Mixed

metho

d2

Goo

d-qua

lity,

mod

erate-sized

sampleforsocial

scienc

es(n

¼32

0),clinical

observation,

usecases,

andsemistruc

tured

interviewswithstaffof

16nu

r-sing

homes

Research

ersdidno

tfollo

wup

survey

swithcalls,no

rdidthey

attempt

toco

ntac

tthose

HIEs

that

didno

trespon

d.Valua

ble

inform

ationco

uldha

vebe

enga

thered

from

theseothe

rmea

nsof

commun

ication

Nursing

homes

Hassole

tal25

Mixed

metho

d2

Goo

d-qua

lity,

mod

erate-sized

sampleforsocial

scienc

es(n

¼27

),su

rvey

aske

dseve

ral

question

sto

HIEsac

ross

the

nation

Research

ersdidno

tfollo

wup

survey

swithcalls,no

rdidthey

attempt

toco

ntac

tthose

HIEs

that

didno

trespon

d.Valua

ble

inform

ationco

uldha

vebe

enga

thered

from

theseothe

rmea

nsof

commun

ication

Long

-term

acute-care

settings

Abram

son

etal5

Cross-sec

tion

al,mixed

metho

ds

2Goo

d-qua

lity,

mod

erate-sized

sampleforsocial

scienc

es(n

¼37

5),clinical

observation,

usecases,

andsemistruc

tured

interviewswithstaffof

16nu

r-sing

homes

Research

erslim

ited

theirstud

yto

thestateof

New

York,w

hich

makes

itdifficu

ltto

applytheir

resu

ltselsewhe

re.Itwou

ldha

vebe

enhe

lpfuliftheresearch

ers

hadco

ntac

tedthenu

rsing

homes

that

didno

trespon

dto

thesu

rvey

topromotetheir

participation

Nursing

homes

Richa

rdso

net

al9

Semistruc

turedteleph

onean

din-perso

ninterviewswithinfor-

maticians

,he

althcare

0Goo

d-qua

lity,

mod

erate-sized

sampleforsocial

scienc

esRe

search

was

cond

uctedwith

inhe

rent

bias

beca

useitwas

Skilled

nursingfacility



Appen

dix

C(Con

tinue

d)

Authors

Studydesign

0¼

Qualitative

1¼

Quan

titative

2¼

Mixed

3¼

Review

4¼

Other

Qua

lity

Critiqu

eof

stud

yCaresetting

administrators,

softwareen

gi-

neers,

andprov

iders

(n¼

18),of

prov

idersan

dad

ministratorsof

aSN

Fwithintheresearch

er’s

own

facility

Cam

pion

etal26

Cross-sec

tion

alretrospe

ctive

stud

yusingseco

ndaryda

ta1

Mod

eratequ

alitywithasm

all

samplesize

forso

cial

scienc

es(n

¼8)

toev

alua

teda

tafrom

HIEsin

New

York

Thisisan

othe

rstud

ythat

was

limited

tothestateof

New

York.

Itwou

ldha

vebe

enbe

tter

ifthe

stud

ywou

ldha

veex

tend

edbe

yond

onestateso

that

resu

lts

couldha

vebe

enmorewidely

applied

Non

e

Lyng

stad

and

Hellesø

27Cross-sec

tion

al,mixed

metho

ds

stud

y2

Goo

dqu

alitywithlargesample

(n¼

1,07

5)interviewed

both

home-he

alth

care

nurses

and

gene

ralp

ractitione

rs

Factorsno

tco

nsidered

were

person

alpreferen

cesforco

m-

mun

icationan

dge

neration

aldifferen

cesin

acce

ptan

ceof

tech

nology

Hom

ehe

alth

Wan

get

al28

Cross-sec

tion

al,mixed

metho

ds

stud

y2

Goo

dqu

ality,

good

sample

(n¼

136)

Thisstud

yde

signseem

edto

bedriven

moreby

budg

etthan

byintention

Long

-term

care

Mac

Tagga

rtan

dTh

orpe

7Ed

itorial

3N/A

Long

-term

care

andpo

st-acu

tecare

settings

Kessleret

al8

Review

3High-qu

alityreview

(n¼

200)

N/A

Geriatric

care

tran

sition

sto

ED

Ham

annan

dBe

zborua

h29

Retrospec

tive,m

ixed

design

,us

ingseco

ndaryda

ta2

High-qu

alityus

inggo

odsample

size

(n¼

1,17

4)us

ingastrati-

fied

,multiph

asesamplingtech

-niqu

efornu

rsingho

mes

across

theco

untry

None

Nursing

homes

Wolfet

al30

Retrospec

tive,q

uantitative

design

,us

ingseco

ndaryda

ta1

High-qu

alityus

inglargesample

(n¼

3,65

3)Th

eda

tasetfrom

theAHAco

uld

have

been

augmen

tedwiththe

datasetfrom

HIM

SSto

corrob

o-rate

tren

dsan

dfind

ings

Long

-term

acuteca

re(n

¼14

4),

reha

bilitation(n

¼10

8),ps

y-ch

iatric

(n¼

240),s

hort-term

acuteca

re(n

¼3,16

1)

Kern

etal11

Long

itud

inal

coho

rtstud

yof

commun

ity-ba

sedorga

nization

sfu

2Mod

erate-qu

ality,

smallsam

ple

size

forsocial

scienc

es(n

¼26

)None

Inpa

tien

tan

dou

tpatient.S

ur-

veys

includ

edallp

articipa

ting

HIE

orga

nization

sin

New

York

state

Abb

reviations

:ACO,acco

untablecare

orga

nization;

AHA,American

HospitalA

ssoc

iation

;EH

R,elec

troniche

alth

reco

rd;HIE,he

alth

inform

ationexch

ange

;HIM

SS,Hea

lthc

areInform

ationan

dMan

agem

ent

System

sSo

ciety;

HIT,he

alth

inform

ationtech

nology;

LTC,long

-term

care.

a Acautionshouldbe

notedthat

inqu

alitativeresearch

,more

isno

tne

cessarily

better

beca

usealarger

sample

might

indica

tealack

ofde

pthof

interview.



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