We found that transitions in care constituted a substantial proportion of patient visits in one community. These visits represent opportunities where an aggregate patient record form of HIE could provide useful information. We found a notable range of transition percentages across specialties, within specialties, and across medical groups even among the modest number of clinicians in the data set.
We identified a few other reports that studied the frequency of care transitions for patients in a community, although most involved narrower clinical samples. For example, one study that investigated the frequency with which an HIE was accessed was restricted to emergency departments.13
Another study evaluated the number of patients who visited more than one emergency department within a geographic region.14
A study of the United Kingdom's effort to share clinical records was also restricted to emergency or unscheduled care settings.17
Other studies that report HIE usage numbers did not focus on appropriate levels of usage based on patient visit patterns.18
If variation in transition percentage among clinicians is common in many communities, meaningful use payments and related policy incentives should consider patient visit patterns, in addition to visit volumes, in estimates of target HIE usage.
Many providers may not access an aggregate record HIE for every care transition for good reason. Some patients' problems may be routine and data in the HIE may be unrelated to the patient's current problem or clinical episode. However, providers will often not be able to determine the relevance of the data without first reviewing them. We suggest that if providers—primary care especially—are to be responsible for coordination of patient care and comprehensive treatment of medical conditions, some fraction of the number of care transitions a provider encounters will represent a reasonable meaningful use target for a provider accessing an aggregate patient record HIE. What that fraction is should be addressed empirically. Which specific data types providers should be expected to view is also an open question and likely varies by clinician's specialty and the setting in which they are seeing the patient, as well as the specific circumstances of the patient's visit. In many clinical scenarios, providers may be expected to check for recent laboratory results, changes in problem lists and medications, or consultation notes.
Some providers may access an HIE even for repeat visits because information from the HIE had not been imported into the provider's electronic health record (EHR) during the previous visit, or because the provider had no way of knowing whether or not new data were present in the HIE. HIE vendors may reduce the need for these accesses, which could be a burden on the provider, by providing functionality that allows automatic importing of HIE data into an EHR and by implementing a visual cue that indicates whether or not new data have been added to the HIE since the patient's previous visit.
Aggregate records in HIEs may not always be comprehensive and include up-to-date information from all providers in the community because some providers may not participate and some may not always contribute data immediately following every patient visit.10
Also, some providers may not have easy access to the HIE. Therefore, realistic usage targets will likely be lower than the estimates in this study but will still be computable from the patient visit patterns of providers who participate in HIEs.
In addition to assessing HIE accesses, meaningful use payments might also consider including accesses to medical groups' EHRs for care transitions within medical groups, which accounted for 10%–15% of visits in the community we studied and may be more or less in other communities, although data exchange is much easier within a group that shares an EHR. This may be especially important for large medical groups in which many patients receive most of their care, because many care transitions will likely occur between providers within those groups and incentives may be needed to ensure care within the group is coordinated.
If measures of HIE accesses are to be used in connection with incentive payments, HIE and EHR vendor companies must offer the capability to report these metrics. It is unlikely that vendors will develop functionalities to report metrics that can be compared across HIEs without some change in their incentives offered. We recommend that vendors should be required to support these metrics as a condition of certification.19
Vendors would likely be able to calculate counts of actual HIE accesses as well as the volume of care transitions from data they already capture in audit trails, although they should not be expected to develop their own algorithms for doing this—development of a single algorithm might be helpful and also could diminish the risk of ‘gaming’ or manipulation of the system.
Gaming is a serious concern; in particular, direct incentives to providers simply to access HIE may not be a judicious approach to encourage meaningful use.20
The risk of gaming should be studied empirically. In addition to being used to assess providers' usage, care transition metrics may also be applied to evaluate and compare the effectiveness of HIE organizations and regional extension centers in engaging clinical users. One option might be to incentivize HIEs in particular to have higher clinician usage rates. We have observed when evaluating a working HIE that the doctors would have benefitted from some simple office training, but the HIE did not have an incentive to provide such training.10
This study has several important limitations. It focused on only one small community and thus may not be generalizable to other care settings. Visit patterns may be different in different types of communities, such as urban settings, and may have more or less variation in transition percentage. In addition, our claims data were limited to the claims submitted to one private payer, so the results may not be generalizable to other payers. Also, visits from patients over 65 years of age or from patients or providers not covered by the payer were not included. We also did not account for providers who changed medical groups during the study period.
In conclusion, in this study within one community, we found that a substantial percentage of patient visits involved care transitions. This finding supports previous studies that identified significant potential use for HIE, especially for aggregate patient records. We also found substantial differences in care transition patterns by type of practice in this community, which suggests that patient visit patterns should be considered when incentives to foster providers' meaningful use of health data exchange functionality are being designed.