# Enhancing Electronic Availability of Hospital Records Following Interhospital Transfer From Emergency Departments to a Veterans Affairs Hospital

## TL;DR

This study shows that a standardized process for uploading medical records from non-VA hospitals to a VA hospital significantly improves the speed and completeness of record availability.

## Contribution

The novel intervention introduces a standardized process for electronic record transmission during interhospital transfers, improving documentation timeliness.

## Key findings

- Before implementation, 40% of transfers had uploaded records, with a median 33-day delay.
- After implementation, 51% of transfers had uploaded records with a median 0-day delay.

## Abstract

With regionalization of specialized care and consolidation of rural hospitals, safe and efficient care transitions via interhospital transfers, particularly for patients in the emergency department (ED), are of paramount importance to ensure optimal patient outcomes. Transferred patients are at higher risk for mortality, longer hospital stays, and increased costs. Complete documentation is central to high quality care transitions yet is infrequently completed. Incomplete documentation may harm patients by fragmenting care. Since the passage of federal legislation, non-Veteran Affairs (VA) emergency care has skyrocketed. However, the lack of a standardized process for medical record sharing following non-VA ED visits and subsequent interhospital transfer risks care interruption and therefore patient safety. We sought to evaluate the existing process and how standardization may affect the timeliness and availability of Veteran hospital records from non-VA hospitals.

This was a quality improvement project conducted at a single, urban, community, level 1 complexity VA—the VA Tennessee Valley Healthcare System, Nashville Campus (TVHS-Na). Before this project, paper medical records related to non-VA emergency care were given to the primary team by the transferring ambulance service. Paper records were then uploaded to the document imaging system at each team’s discretion, typically after hospital discharge. To understand the problem and flow of records, we conducted a contextual inquiry. From there, we developed and implemented a standardized process to receive and upload electronic health records before the patient arrived at the hospital for all daytime weekday transfers. After-hours transfers maintained existing processes. The project had a Plan-Do-Study-Act design, informed by the VA Quality Enhancement Research Initiative Roadmap.

The project was approved as a quality improvement project by the local institutional review board. Interhospital transfers were tracked from January 2024 to September 2024. All transfers from a non-VA ED to TVHS-Na as a direct hospital floor admission were included. The primary outcomes were time until availability of scanned records and percent of transfers with uploaded records as identified in the document imaging system.

Through a contextual inquiry with stakeholders, we identified that intervention at the time of transfer acceptance was possible with the help of transfer coordinators. As part of the novel intervention, coordinators would ask transferring hospitals for electronic transmission of certain optional documents. This would occur before the physical transfer of the patient. Over the project’s course, there were 157 interhospital transfers from non-VA EDs that met eligibility. Before implementation, the median (interquartile range, IQR) time to document availability was 33 (24, 36) days. The proportion of transfers with uploaded records at this time was 40% (13/32). Ten transfers occurred during the “washout phase” during which the intervention was implemented. After implementation, the median (IQR) time until upload improved to 0 (0, 0) days. The proportion of transfers with uploaded records also improved to 51% (59/115).

Implementing a simple, standardized process increased the number of transfers with available records and reduced the time until the electronic availability of those records. However, after-hours transfers remain a target for future intervention.