Regional data exchange to improve care for veterans after non-VA hospitalization: a randomized controlled trial

Abstract

Background: Coordination of care, especially after a patient experiences an acute care event, is a challenge for many health systems. Event notification is a form of health information exchange (HIE) which has the potential to support care coordination by alerting primary care providers when a patient experiences an acute care event. While promising, there exists little evidence on the impact of event notification in support of reengagement into primary care. The objectives of this study are to 1) examine the effectiveness of event notification on health outcomes for older adults who experience acute care events, and 2) compare approaches to how providers respond to event notifications.

Methods: In a cluster randomized trial conducted across two medical centers within the U.S. Veterans Health Administration (VHA) system, we plan to enroll older patients (≥ 65 years of age) who utilize both VHA and non-VHA providers. Patients will be enrolled into one of three arms: 1) usual care; 2) event notifications only; or 3) event notifications plus a care transitions intervention. In the event notification arms, following a non-VHA acute care encounter, an HIE-based intervention will send an event notification to VHA providers. Patients in the event notification plus care transitions arm will also receive 30 days of care transition support from a social worker. The primary outcome measure is 90-day readmission rate. Secondary outcomes will be high risk medication discrepancies as well as care transitions processes within the VHA health system. Qualitative assessments of the intervention will inform VHA system-wide implementation.

Discussion: While HIE has been evaluated in other contexts, little evidence exists on HIE-enabled event notification interventions. Furthermore, this trial offers the opportunity to examine the use of event notifications that trigger a care transitions intervention to further support coordination of care.

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

Keywords: Community networks; Emergency service; Health information exchange; Hospital; Hospitalization; Reminder systems; Veterans health.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1

Overview of the study population, study arms, and phases of the study. VA = Veterans Affairs

Fig. 2

Information flow when a patient has a non-VA acute care encounter. Event notifications are sent via the regional HIE network to the VA for patients in all arms. A coordinator at the VA enters the notification as a note into the EHR for the primary care team to review and co-sign for patients enrolled in arms 1 and 2. For patients in arm 2, a care transition intervention is activated for 30 days post-discharge. VA = Veterans Administration; HIE = Health information exchange; HL7 = Health Level 7; EHR = Electronic health record

Fig. 3

Screenshot of a non-VA encounter note entered into the VA EHR for a patient in either study arm 1 or arm 2. The note must be acknowledged by a member of the patient’s primary care team

Fig. 4

Overview of patient screening, enrollment, and activation procedures performed by research staff. The figure distinguishes between study arm 1 (notification only) and arm 2 (notification plus care transitions intervention)