Safe Interorganizational Health Information Exchange During the COVID-19 Pandemic

HOPE leadership identified currently existing SNF processes that could be built on for the solution, to minimize the burden of navigating new software systems or workflows. Communication mechanisms between HOPE Collaborative SNFs and our hospital system in the pre-COVID-19 phase included a transfer center phone number where SNF personnel give verbal sign-out when sending a patient to the emergency department; a secure online document-sharing website; and an electronic health record (EHR) portal where SNF staff review inpatient medical records and upload documents to the patient's chart. Among other suggestions, use of the portal and file-sharing site was considered, but logistical issues precluded use of these mechanisms. HOPE leadership reached out to others in health system technology support, online portal management, and SNF leadership to draft possible solutions. The list of considered solutions is described in Table 1.

For several reasons, our accepted solution involved using software that would transform SNF fax input into data fully integrated into the EHR. First, fax is currently available at all local SNFs and did not require additional equipment, training, or security access. On the hospital end, health information management already used a secure fax to receive records, so no new infrastructure was needed. Second, it built on existing processes. Administration and compliance officers were familiar with the workflow in other settings, so approval was expedited. The health system had a pre-existing contract with the data integration vendor, who waived initiation costs for new COVID-19–specific workflows. Third, the software integrated SNF data into appropriate areas of the EHR (eg, advance directives colocated with other advance care planning documents). Records needed to be easily accessible to inpatient providers, to reduce cognitive burden and facilitate clinical care.

After this process was approved by hospital leadership, the next step was introducing it to SNFs and hospital staff. A communication was sent to local SNFs via e-mail with instructions that included the fax number for each of our health system's hospitals, a list of important documents to send, and an updated 2-step workflow asking SNFs to first call the transfer line (part of their existing workflow) and then fax records. HOPE leadership created a flyer that could be posted at SNF nursing stations and promoted the process during monthly HOPE webinars and in educational e-mails. On the hospital end, educational tip sheets were created for hospitalists, case managers, pharmacists, and other team members. One-time e-mail communications were sent to hospital staff by hospital leadership.

On the first day this process was implemented, a COVID-positive patient was transferred from an SNF to the hospital. The SNF used this process successfully, with documents integrated in the EHR in approximately 1 hour.

In the 9 weeks since implementation, the process has been used 287 times throughout our 3-hospital health system, with overall increasing usage as shown in Figure 1. Week 1 usage was high in part because of receipt of requested records for patients already admitted; all other data points were spontaneous file transfers from SNFs to the hospital. There were weekly fluctuations in usage. This may be due in part to fluctuations in hospital transfers related to COVID-19 over the same time frame, as well as normal variation in SNF to hospital transfers for other acute problems. Timing of education and outreach promoting the e-fax process did not directly correlate with timing of increased usage. The overall increasing trend with education and time suggests that consistency in use is improving.

The only new cost incurred was the price per document for each incoming fax, to achieve the 1-hour turnaround time.

Collaborative models between academic hospital systems and local SNFs have demonstrated improved relationships and continuity of care supporting quality patient care during the COVID-19 pandemic. HOPE Collaborative leadership was able to take action quickly since the beginning of the pandemic because of our strong relationships with SNFs and an established leadership team. We were familiar with the unique challenges that exist in SNFs, including frequent staff turnover, limited technological resources, and dealing with the processes of multiple hospitals and health systems, and Collaborative SNFs trusted us to provide quality education, communication, and assistance. Other health systems without these building blocks may have a slower response in order to build relationships, understand processes, and identify team members. From the first brainstorming session to day 1 of implementation, this process took less than 2 weeks. To date, it has been in use for 9 weeks, and feedback from SNFs and hospital teams has been positive. Two issues were identified during implementation: on a few occasions, only 1 side of a 2-sided document was received; on another occasion, there was a data integration delay of more than an hour. These have been resolved with education and troubleshooting. One limitation is that our hospital system was not previously tracking patient admission source information (ie, whether they came from home, congregate living, etc) and so we are unable to accurately tell what percentage of patients admitted from SNFs are using the e-fax process. We have since updated EHR documentation to capture and track that data moving forward. A summary of key implementation factors is described in Table 2; without these, attempts at improving interoperability of health information exchange have been less successful.

Our relationship with collaborative members helped us quickly identify the logistical challenges facing SNFs with each of the suggested solutions, and advocate for a process that would be feasible and efficient. The new workflow, borne out of necessity developed during the COVID-19 crisis, is a critical improvement over the previous process, which will continue to be used after the pandemic has concluded.