BOSTON — A greater volume of health information exchange, the electronic sharing of patient medical information among healthcare organizations, appears to affect patient outcomes for community care and VHA direct care settings differently. In one setting, it improves patient outcomes, but, in the other, the effects are neutral or adverse, a recent study suggested.
Electronic health information exchange has the potential to enhance care coordination, reduce medical errors and prevent unnecessary use, according to the report published in the Journal of the American Medical Informatics Association.1
Healthcare delivery systems have invested considerably in health information exchange infrastructure and promoting use of this technology. For instance, the VA has enhanced the Veterans Health Information Exchange system, which launched in April 2020 and enables VHA and participating community-based delivery systems to securely share records for approximately 9 million enrollees.
Because veterans often use both VHA and non-VHA sources of care, which creates the potential for significant care fragmentation, health information exchange is especially important, according to the study led by Boston University School of Public Health and the VA Boston Healthcare System. They pointed out that need for further care coordination with the 2018 MISSION Act that expanded VHA-paid networks of private providers. The average VHA medical center exchanged health information with two or more outside organizations for nearly 35,000 veterans each month.
Despite significant investment in the Veterans Health Information Exchange system, thorough studies of the system’s impact on clinical outcomes are limited. Also, differences in the impact of health information exchange between VHA direct and community care settings are understudied. The researchers explained that community providers can access the VHA’s nationally integrated clinical record, but information coming back to VHA from community providers often involves encounter-specific documentation from multiple organizations. With veterans’ reliance on VHA for most primary care, that limits what any single community partner can contribute to an inbound exchange.
For the study, the investigators used electronic health records to obtain data on VHA enrollees, including patient demographics, clinical characteristics and health services utilization, from January 2022 to December 2023. Since the VHA has contracted with private-sector providers to fill appointments for hundreds of thousands of veterans each year since 2014, referred to as community care, the data include healthcare utilization across both VHA and community care settings.
Health information exchange volume, the number of unique patient-days with completed exchanges, was the key explanatory variable. Primary outcomes for the study were 30-day readmissions, avoidable hospitalizations and in-hospital mortality.
The authors found that, in community care, a 1-standard deviation increase in health information exchange volume was associated with 4.07 fewer 30-day readmissions, 1.45 fewer avoidable hospitalizations, and 0.25 fewer inpatient deaths per medical center per month. In VHA direct care, however, the same increase in health information exchange volume was associated with 7.07 additional readmissions and 0.19 additional inpatient deaths, with no significant impact on avoidable hospitalizations.
“This study provided fairly strong evidence that access to information through health information exchange improves select patient outcomes,” Joshua R. Vest, PhD, MPH, co-author of a similar study on enterprise health information exchange told U.S. Medicine. Vest, who was not involved in the VA study, is a professor and associate dean for research at the Indiana University Richard M. Fairbanks School of Public Health and the interim chief research officer for the Regenstrief Institute.
“Fragmented and inaccessible information is a burden to physicians and other clinicians in the U.S. Studies such as this one are critical in demonstrating the value of investing in the technology that makes information easier to access,” he pointed out. “Systems such as the Veterans Health Information Exchange (VHIE) exist across the nation, but are often underused. The biggest take-away is that, when health information exchange is used, it can result in beneficial outcomes.”
The study’s findings are among the earliest evidence of the clinical impact of the VHA’s investments in information management and sharing, the researchers explained.
The investigators noted the differences in effects of health information exchange across VHA and community care settings. They observed that the same increase in health information exchange volume could improve outcomes in one setting, but have neutral or adverse effects in the other.
Vest suggested that differences in outcomes (30-day readmissions, avoidable hospitalizations and in-hospital mortality) between community care and VA direct care settings are likely due to the nature and format of the information exchanged. He said the VA’s relationship with community providers afforded a nuanced analysis of information exchange. As the authors pointed out, the depth and richness of the data originating in the VA is probably more valuable to patient care, he noted.
In the research paper, the authors proposed the community care result indicates that scaling health information exchange volume promotes quality in settings where it is filling an information gap. Meanwhile, the VHA direct care result warrants further examination of how external information is displayed and integrated into VHA clinician workflows, along with investigations of possible shifts in case mix between settings driven by health information exchange. There are well-established case mix differences between dual-system and VHA-only veterans.
According to the investigators, one explanation for these differences could be that longitudinal patient histories that flow from VHA to community partners are more valuable than the irregular summaries that flow back from community partners to VHA. Also, the user interface that delivers exchanged information may be more intuitive and actionable in the modern electronic health records used by community partners than in the read-only Joint Legacy Viewer used by most VHA facilities. Lastly, increased health information exchange enables VHA providers to reclaim care from community providers, shifting more patients back into VHA care.
If risk stratification can be verified when a return to VHA care is prompted by health information exchange, returning veterans may benefit from targeted post-acute transitional care and readmission prevention strategies, the authors pointed out.
The researchers suggested that understanding how health information exchange affects outcomes can help policymakers and clinical stakeholders better direct health IT investments toward improving care delivery. They recommended that future studies are needed to examine health information flow, provider experience, and the conditions under which health information exchange translates into meaningful improvements in care.
- Zhang A, Lipsey D, Figueroa S, Price ME, Nebeker J, Pan ECR, Griffith K, Pizer SD. Veteran health information exchange volume and 30-day readmissions, avoidable hospitalizations, and in-hospital mortality: evidence from community and Veterans Health Administration direct care. J Am Med Inform Assoc. 2026 Jul 28:ocag125. doi: 10.1093/jamia/ocag125. Epub ahead of print. PMID: 42515823.
