Patients transferring to skilled nursing facilities (SNF) from hospitals to recuperate from illness or injury often bring with them a need for complex care along with a thick packet of printed medical information. To improve the transition and process of sorting through the information, SNFs are increasingly being granted access to view patient hospital electronic health records (EHRs) through what are called health information exchange (HIE) portals. However, new research from the School of Public Health shows the use of such portals in nursing facilities is languishing due to multiple barriers to their timely and consistent use.
“We know that patient handoffs between hospitals and skilled nursing facilities are inherently difficult. Electronic information sharing can bridge the information discontinuity between the hospital and SNF and improve patient care,” says lead author and Assistant Professor Dori Cross. “Unfortunately, we found the implementation of such systems is not being done well, and consequently, they’re being underused.”
The study was recently published in The American Journal of Managed Care.
During the typical handoff from a hospital to a SNF, the patient arrives by ambulance hand-carrying a discharge packet detailing their care and health records. A hospital nurse also makes a phone call to SNF nursing staff to provide important, nuanced info about the patient not easily found in the discharge packet, such as preferences for interaction with nursing staff or the last timing of wound irrigation. Computer-based HIE portals, which essentially provide SNFs with “view-only” access to hospital EHRs, are intended to supplement the usual handoff process by making it easier for SNF staff to directly search for additional necessary information that wasn’t conveyed by phone and is unavailable or difficult to find in the paper discharge packet.
To gauge how well the portals are being implemented, Cross studied the use of one such system shared by a large academic medical center and three local SNFs. In June 2014, the hospital extended an HIE portal to the SNFs to allow them to read patient EHR files. Administrators, nursing directors, and, occasionally, nurse unit managers were granted access to the portal. Physicians practicing in the SNF had full access to the hospital EHR, and therefore, did not require portal access.
The study found:
- Health information exchange was used by SNFs for 46 percent of patients for whom it was available.
- 29 percent of patients had records accessed within three days of hospital discharge.
- Overall, HIE portal use was more likely for new versus returning SNF patients and when a patient was discharged from the emergency department rather than an inpatient unit.
- HIE portal use was less likely on weekends and for more complex patients.
Cross believes the low use of the HIE portal was due to how the system was implemented.
“Nursing staff weren’t provided with training or directed use cases. There wasn’t follow-through to understand how well the system is working and what was preventing use in contexts where it could be helpful.” says Cross. “As a result, staff didn’t see its value and set it aside.”
Cross said the design of the system was also a limiting factor because the portal wasn’t geared toward what SNFs need and lacked or omitted hospital information that could help them provide better care, such as patient social and family history contained in notes documented by hospital nurses and social work staff.
To make better use of HIE portals, Cross recommends that hospitals and SNFs strengthen collaborative efforts to modify system design and information accessibility as well as include elements specific to the needs of SNF providers. SNFs could also use these opportunities or existing SNF-specific community forums to share experiences with targeted ways of using the portal (i.e. what information is available, and how) that have been found valuable. Understanding where value does exist — and can exist — will help SNFs approach the system’s use in a more consistent and sustained way.
As part of this same, larger study, Cross is conducting further research to see if HIE portal use by SNFs reduces patient hospital readmission rates. cross is also working on capturing data on the variation in the breadth and depth of information being retrieved by nursing staff using these systems.