The transfer of patients between acute care hospitals (inter-hospital transfer, IHT) is
often undertaken to provide patients with needed specialized care that is unavailable at
the transferring hospital. IHT occurs regularly, with over 100,000 Medicare patients
undergoing IHT annually and with higher frequency among patients with select medical
conditions (i.e., acute myocardial infarction), those who are critically ill, and those
with multiple chronic conditions (MCC). Although all hospital-based care transitions
expose patients to the risks of discontinuity of care, patients who undergo IHT are
highly vulnerable to these risks given their illness severity and the fact that IHT
involves transfer between providers, settings, and systems of care, thereby lacking
potential safe-guards against potential gaps in communication.
The overall goals of this study are to leverage the investigators' extensive research
experience in IHT and health information technology innovation, including an in-depth
understanding of the essential clinical information required for effective HIE, to
design, implement, and rigorously evaluate an intervention to improve HIE during IHT. The
investigators propose to implement the intervention in 3 use cases with different levels
of integration between sending and receiving hospitals. The platform will use existing
data standards to ensure interoperability while also optimizing data visualization and
workflow. The investigators will then evaluate the effects of the intervention on medical
errors and adverse events, evaluate use and usability of the platform, and conduct a
mixed methods evaluation to identify best practices for further refining, disseminating,
implementing, and sustaining this intervention across different institutions. To achieve
this, the Specific Aims of this study are:
Aim 1: To utilize user-centered design principles and prior knowledge and experience of
essential information required during IHT to refine a currently functional inter-operable
HIE platform that improves reliability of and access to necessary clinical information
during IHT and to implement it in 3 use cases: hospitals within the same health system,
hospitals in different systems that share a common EHR, and hospitals in different
systems that use different EHRs.
Aim 2: To evaluate the impact of this intervention on clinician-reported medical errors;
medical errors attributable to sub-optimal information exchange; adverse events; and
other measures of patient safety and workflow, using interrupted time series methodology.
Aim 3: To evaluate the utilization and perceived usability of the HIE platform from the
perspective of users who interact with the platform, including clinicians who transfer
and accept IHT patients, clinicians at accepting hospitals who admit transferred
patients, medical records personnel at transferring hospitals, and access center
personnel at accepting hospitals; and identify facilitators and barriers to
implementation.
Aim 4: To combine data on use, usability and barriers to implementation from end-users
with input from steering committee members to develop a plan for further refinement of
the platform and a toolkit for widespread adoption at MGB and dissemination to other
similar organizations.
The proposed study will provide a novel, user-centered implementation and evaluation of
HIE in order to improve the quality of care and patient outcomes during IHT, an
understudied, high-risk care transition impacting a vulnerable patient group. This study
includes a purposeful evaluation of IHT between hospitals with different levels of
affiliation and EHR integration, in addition to rigorous evaluation of use and usability,
and barriers and facilitators of implementation across different institutions to identify
best practices for dissemination and implementation. The lessons learned will be used to
inform successful and sustained adoption by other health care systems, thus broadly
improving care provided to transferred patients.