Association between Health Information Exchange and Health Outcomes in Older Patients Transferred from Long-term Care to the Emergency Department: A Retrospective Review

Article information

J Korean Acad Fundam Nurs. 2025;32(2):243-252

Publication date (electronic) : 2025 May 31

doi : https://doi.org/10.7739/jkafn.2025.32.2.243

Hyung Jun Kim ¹⁾

, Suyoung Choi ²⁾^,

¹⁾Nurse, Jeju National University Hospital, Jeju, Korea

²⁾Associate Professor, College of Nursing ‧ Health and Nursing Research Institute, Jeju National University, Jeju, Korea

Corresponding author: Choi, Suyoung College of Nursing, Jeju National University 102 Jejudaehak-ro, Jeju 63243, Korea Tel: +82-64-754-3753, Fax: +82-64-702-2686, E-mail: schoi@jejunu.ac.kr

*This article is a revision of the first author's master's thesis from Jeju National University.

Received 2025 January 26; Revised 2025 April 1; Accepted 2025 May 19.

Abstract

Purpose

This study investigated the association between the level of health information exchange (HIE) and health outcomes in older patients transferred from long-term care settings to the emergency department (ED). It focused on the relationship between HIE and ED length of stay, hospital length of stay, and unexpected ED revisits.

Methods

A retrospective analysis was conducted of medical records for 452 cases involving 362 patients aged ≥65 years, transferred to the ED of a university hospital from July 2017 to June 2018.

Results

The mean number of exchanged health information items was 1.33±2.45. Long-term care hospitals exchanged significantly more information than long-term care facilities (Z=-13.81, p<.001). A significant negative correlation was observed between the level of information exchange and ED length of stay (ρ=-.160, p=.001), suggesting that more extensive HIE may reduce the time older patients spend in the ED. However, no significant correlations were found between HIE and hospital length of stay or unexpected ED revisits.

Conclusion

These results highlight the urgent need to improve HIE practices. Further studies are needed to investigate other factors that may influence long-term health outcomes and the effectiveness of health systems in managing older patients transferred to long-term care settings.

Keywords: Aged; Emergency service; hospital; Health information exchange; Long-term care; Patient transfer

INTRODUCTION

The use of emergency departments (EDs) by older patients has increased rapidly in developed countries, including South Korea, due to population aging [1-3]. In South Korea, 92,093 elderly patients (aged ≥60) visited EDs in 2022, accounting for 52.8% of all emergency department (ED) cases [3]. Since Korea implemented long-term care insurance in 2008, the number of long-term care (LTC) facilities and hospitals has significantly risen, serving elderly patients requiring prolonged hospitalization or high physical dependence, often necessitating ED transfers [4]. Despite advances in electronic health records (EHRs) and digital health systems, substantial gaps persist in health information exchange (HIE) between LTC settings and EDs. Recent studies highlight ongoing problems with incomplete or missing patient records at ED admission, resulting in delayed diagnoses, treatment inefficiencies, and prolonged hospital stays [1]. Additionally, adoption of standardized HIE tools, such as structured transfer forms, remains inconsistent, with low compliance and variable documentation quality across LTC settings [5]. These challenges underscore the continued need to investigate the association between HIE completeness and patient outcomes during LTC-to-ED transfers.

Common emergencies among elderly LTC residents include rapid vital sign changes, delirium, fractures, dyspnea, seizures, and cardiac events [6,7]. These patients often exhibit severe or atypical symptoms, cognitive impairments, and multiple comorbidities, complicating communication and prolonging ED stays [6,8,9]. Consequently, their mortality rates are 1.5∼2 times higher than those of community-dwelling older adults [10-12]. Effective HIE during transfers is crucial for ensuring continuity of care, as elderly patients frequently struggle to communicate their medical histories clearly [1,11]. Ensuring continuity of care through effective HIE is essential for safeguarding patient health during transfers. Effective HIE correlates with improved outcomes, such as shorter ED stays, reduced hospitalization periods, and fewer unplanned ED revisits [13]. Accurate and detailed health records can also minimize unnecessary tests, decrease treatment errors, and expedite ED processes, enhancing overall emergency care quality [14].

Despite these benefits, recent studies consistently highlight substantial gaps and inconsistencies in HIE from LTC to ED settings. Critical patient details such as medical history, vital signs, cognitive status, medications, functional abilities, allergies, and vaccination records are frequently missing or incomplete, hindering patient assessment and timely care [14-18]. Recent systematic reviews further emphasize that, despite technological advances, documentation quality and consistency remain inadequate. The ongoing lack of standardized communication tools urgently needs addressing, especially for vulnerable elderly populations at high risk for adverse outcomes due to communication failures [19,20]. The Joint Commission on Accreditation of Healthcare Organizations in the U.S. emphasizes that up-to-date health information-covering care, treatment, and recent changes in patient status-should be provided during ED presentations. Previous studies have shown that standardized transfer forms significantly enhance HIE, shortening ED visits, decreasing hospitalizations, and reducing readmission rates [5,19,21,22].

In Korea, few studies have investigated HIE among elderly patients, and no standardized system currently exists for emergency transfers, limiting effective information exchange. This study addresses this gap by assessing HIE and its association with health outcomes (ED length of stay, hospital stay, and unplanned ED revisits), providing evidence for developing a standardized HIE system tailored to LTC settings.

METHODS

1. Study Design

This retrospective study aimed to determine the level of HIE among elderly patients transferred from LTC settings to the ED, and to identify the association between HIE and health outcomes, including ED length of stay, hospital length of stay, and unplanned ED revisits.

2. Participants and Data Collection

Data were collected through retrospective review of electronic medical records (EMRs), emergency medical histories, nursing records, and transfer forms. The study included elderly patients aged ≥65 years who visited the ED at a University Hospital in Jeju City from July 1, 2017, to June 30, 2018, after being transferred from long-term care settings. Exclusion criteria included patients visiting the ED for simple treatments such as gastrostomy changes, nephrostomy changes, arteriovenous fistula malfunctions, tube/catheter changes, blood tests, transfusions, and wound dressings. Of the 11,692 medical records of 7,595 elderly patients who visited the ED during the data collection period, 531 records of 422 patients were excluded due to 79 exclusion criteria. A total of 452 records from 362 patients were analyzed (Figure 1).

Figure 1.

Flow chart of subject selection.

3. Measures

1) Participants’ characteristics

General characteristics included gender, age, reason for ED visit, outcomes following ED visit, and hospitalization type. Disease-related characteristics comprised consciousness and Charlson Comorbidity Index (CCI) scores. Consciousness was assessed using the AVPU scale: alert (A), verbal response (V), pain response (P), and unresponsive (U). The AVPU scale offers a simplified, rapid tool commonly used in emergencies, demonstrating strong inter-rater reliability (Cohen's kappa=.62), comparable to Glasgow Coma Scale components [23,24]. The CCI quantifies comorbidities based on their associated 1-year mortality risk, assigning higher scores to more severe conditions [25]. Comorbidities scored include myocardial infarction, congestive heart failure, peripheral vascular disease, cere-brovascular disease, dementia, chronic pulmonary disease, connective tissue disease, ulcer disease, mild liver disease, and diabetes (1 point each); hemiplegia, diabetes with complications, moderate-to-severe renal disease, solid tumors, leukemia, and lymphoma (2 points each); moderate-to-severe liver disease (3 points); and metastatic tumors and AIDS (6 points each)[25]. The reliability and predictive validity of the CCI are well-established across medical, surgical, intensive care, and ED populations [26].

2) Health information exchange

The health information items assessing HIE were based on Tsai and Tasi's ED transfer checklist [21], which specifies essential patient data required during transfers from LTC to ED settings. This checklist was adapted to the Korean context, comprising 19 items, guided by previous studies [14,16,18,22,27]. Content validity was reviewed by two nurses with over 10 years of ED experience and one geriatric nurse practitioner. The revised checklist included institutional information (facility name, contact details, guardian's contact) and patient-related information (transfer reason, medical history, initial vital signs, cognitive/ consciousness status, communication ability, activities of daily living or functional status, mobility, advance directives, medications, vaccination and allergy history, incontinence, nursing notes, test results, and transfer forms). The extent of HIE was quantified as the total number of documented health information items provided upon ED arrival.

3) Health outcomes

Health outcomes were measured by ED length of stay, hospital length of stay, and unplanned ED revisits. ED length of stay was calculated as the total time, in minutes, from ED arrival to admission, transfer, or discharge. Hospital length of stay was measured in days from ED discharge to admission and subsequent discharge. Unplanned ED revisit was defined as a return within 72 h for the same primary symptom.

4. Data Analysis

Data were analyzed using SPSS Statistics version 23.0(IBM Corp., Armonk, NY, USA). Participant characteristics were summarized using means, standard deviations, frequencies, and percentages. HIE was quantified by frequency and percentage. The distribution of ED length of stay, hospital length of stay, and HIE were assessed for normality using the Shapiro-Wilk test, as well as skew-ness, and kurtosis indices. Given that HIE data were count-based and both ED and hospital length of stay variables exhibited significant non-normality, non-parametric tests were employed to enhance the robustness of the findings. Differences in HIE and health outcomes by institution type were analyzed using the Mann-Whitney U test, x² test, and Fisher's exact test, as appropriate. Associations between HIE and health outcomes were examined using Spearman's rank correlation coefficients.

To evaluate whether the level of comorbidity influenced these associations, participants were categorized into two groups based on the CCI. Based on the original validation by Charlson et al. [25], a CCI score of ≥3 was considered indicative of high comorbidity due to its association with over 50% 1-year mortality. Accordingly, participants were divided into low (CCI < 3) and high comorbidity (CCI≥3) groups. Correlation coefficients between HIE and health outcomes were computed separately for these groups, and Fisher's z-test was performed to statistically compare correlation differences, thus determining whether associations differed significantly by comorbidity level.

5. Ethical Consideration

The study was approved by the institutional review board of researcher-affiliated institution (IRB No. JEJU NUH 2018-06-017). Institutional approval was obtained for the use of patient medical records, and all procedures complied with ethical guidelines. To ensure patient confidentiality, all data were fully anonymized and coded before analysis. No identifiable personal information was included in the dataset. The data were securely stored on a restricted-access computer, accessible only to the researchers, and will be retained for three years before being permanently destroyed.

RESULTS

1. Participant Characteristics

This study included 452 elderly patients’ cases transferred from LTC settings to the ED, comprising 302 (66.8%) women, with a mean age of 82.58±7.92 years. Regarding institution type, 275 (60.8%) cases were from long-term care facilities (LTCFs), and 177 (39.2%) were from long-term care hospitals (LTCHs). The reason for ED visits was illness in 425 (94.0%) cases, while 27 (6.0%) cases were due to trauma. Alertness was the most prevalent in 269 (59.5%) cases during presentation, with a mean comorbidity score of 2.84±1.91; 221 (48.9%) had a score of ≥3. Outcomes after ED visits, 278 patients (61.5%) required hospitalization, while 152 (33.6%) were discharged, 15 (3.3%) died, and 7(1.5%) were transferred. Of the 278 hospitalized patients, 195 (70.1%) were eventually discharged, 33 (11.9%) transferred, 3 (1.1%) discharged against medical advice, and 47 (16.9%) expired during hospitalization (Table 1).

Table 1.

General and Disease-related Characteristics of the Subjects (N=452)

2. Health Information Exchange for Elderly Patients Presenting to the ED

The average number of HIE items for elderly patients transferred to the ED from LTCHs and LTCFs was 1.33±2.45. Patients from LTCHs had a significantly higher number of exchanged items compared to those from LTCFs (Z=-13.81, p<.001). Among institution-related HIE items, the institution's name (23.2%), while patient-related HIE predominantly consisted of medical history (23.5%).

When comparing institution-related HIE, LTCHs had significantly higher documentation rates than LTCFs (x²=205.90, p <.001). Similarly, patient-related HIE was significantly more frequently exchanged in LTCHs than in LTCFs (x²=187.19, p<.001). In LTCH transfers, 58.8% of cases included both the institution's name and medical history, while 0.0% documented vaccination history, fecal or urinary incontinence, or nursing notes. Among LTCF transfers, only 1.8% recorded current medication history, 0.7% included medical history and vital signs, and 0.4% contained institution name information (Table 2).

Table 2.

Health Information Exchange and Health Outcomes according to Referring Institution (N=452)

3. Health Information Exchange and Health Outcomes

A significant negative correlation was observed between overall HIE and ED length of stay (ρ=-.160, p=.001). Specifically, institution-related HIE (ρ=-.160, p=.001), and patient-related HIE (ρ=-.153, p=.001) both demonstrated significant negative correlations with ED length of stay. No significant correlations were found between HIE and hospital length of stay or unplanned ED revisits (Table 3). Fisher's z-test revealed no significant differences between comorbidity groups for ED length of stay correlations, suggesting consistency irrespective of comorbidity level (Table 3).

Table 3.

Correlations between Health Information Exchange and Health Outcomes (N=452)

DISCUSSION

This study examined HIE during transfers of elderly patients from LTC settings to EDs and investigated its associations with ED length of stay, hospital length of stay, and unplanned ED revisits.

The mean CCI was 2.84, with LTCH patients showing significantly higher scores (3.46) than LTCF patients (2.43), indicating greater disease severity among LTCH patients. This aligns with previous findings that elderly patients transferred from LTC settings often exhibit higher disease burdens than community-dwelling counterparts [8,11]. Hospitalization was the predominant outcome after ED visits for both LTCH (68.9%) and LTCF (56.7%) patients, consistent with prior reports of 60∼75% hospitalization rates among elderly ED patients [4,28]. Mortality rates differed notably; no deaths occurred among LTCH patients, whereas LTCF patients had a mortality rate of 5.5%, possibly reflecting poorer baseline health conditions [7,8,29].

On average, only 1.33 of the 19 required HIE items were exchanged during elderly patient transfers from LTCFs and LTCHs, with compliance particularly low in LTCFs. Although the Korean Emergency Medical Care Act mandates documentation of institutional and guardian contact details on ED transfer forms, only 22.8% of cases included this form. LTCHs provided significantly more health information than LTCFs-medical history was included in 58.8% of LTCH transfers versus just 0.7% in LTCFs, and reasons for transfer were present in 57.6% of LTCH cases but absent in all LTCF transfers. These disparities likely stem from staffing differences, as LTCFs often lack full-time physicians and rely on caregivers or nursing aides, leading to fragmented documentation [15]. Furthermore, LTCHs frequently employ nursing assistants over registered nurses due to recruitment barriers and nursing grade regulations, despite the central role of nurses in ensuring continuity of care [30]. Thus, establishing clear legal standards for securing professional nursing staff at LTCFs, which serve high-risk elderly populations, is urgently needed. Systematic improvements in nurse staffing are crucial for accurately assessing patient conditions and ensuring effective HIE in LTC settings. Notably, essential patient data-including cognitive and communication status, advance directives, activities of daily living, allergies, immunization records, incontinence, nursing notes, and lab results-were entirely absent in LTCF-to-ED transfers. These findings underscore the urgent need for standardized documentation systems and staffing reforms to ensure complete, accurate, and consistent HIE, thereby improving patient safety and care continuity [14,16,18,22].

This study found that greater HIE was significantly associated with shorter ED length of stay, particularly for institution-related and patient-related HIE items. These results align with prior research indicating that comprehensive HIE can reduce ED processing times by minimizing redundant assessments and expediting treatment decisions [14,27,31]. Further analyses demonstrated that this beneficial effect was consistent regardless of patient comorbidity levels, suggesting the robustness of HIE's independent influence on ED length of stay. This finding emphasizes that effective and structured information exchange practices during patient transfers can universally enhance ED efficiency, even among elderly patients with significant underlying health issues.

No significant correlations were observed between HIE and hospital length of stay or unplanned ED revisits, contrary to prior findings from studies on community-dwelling elderly that reported associations between HIE and reduced hospitalization durations [31]. The revisit rate in this study (1.8%) was lower than the 2.2∼2.9% reported in other Korean studies [9,32]. This lower rate may reflect LTCF residents’ and guardians’ preferences to avoid repeat hospital visits due to costs, inconvenience, or end-of-life considerations. Nevertheless, comprehensive HIE remains crucial in elderly populations with atypical symptoms and multiple comorbidities to reduce diagnostic uncertainty and enhance long-term health outcomes [33,34].

Given significant gaps in HIE compliance, legislative and institutional reforms are necessary to standardize LTC-to-ED transfer documentation. Countries like the United States and Canada have effectively implemented standardized transfer forms, improving HIE and patient outcomes [4,22,35]. Korea should similarly mandate structured electronic transfer forms in LTCFs. Additionally, addressing LTCF staffing shortages is essential, as inadequate nursing staff contributes to incomplete documentation. Policies ensuring that trained healthcare professionals accompany patients during transfers would significantly enhance information sharing and continuity of care.

This study has several limitations. First, its retrospective design might not have fully captured informal communication (e.g., verbal reports, phone calls), potentially limiting HIE completeness. Prospective studies should examine real-time and informal exchanges. Second, although comorbidity (CCI) was considered, other important factors like functional status, frailty, and facility-specific transfer protocols were not controlled, which future research should address. Third, this study focused on immediate outcomes (ED length of stay, hospital length of stay, and unplanned ED revisits) without evaluating long-term effects such as functional decline, rehospitalization, or mortality. Longitudinal studies examining these outcomes are recommended. Fourth, despite identifying significant differences in HIE between LTCFs and LTCHs, institutional factors causing these disparities were not investigated. Future studies should explore staffing, resource availability, and administrative practices. Finally, HIE assessment relied solely on documentation presence rather than quality or clinical importance. Future research should develop weighted scoring methods reflecting clinical relevance. Despite these limitations, this study provides valuable insights into HIE during elderly patient transfers from LTC settings to EDs. It identifies significant gaps in information exchange, emphasizing the need for standardized HIE documentation protocols to enhance emergency care coordination.

CONCLUSION

This study examined HIE during elderly patient transfers from LTCFs and LTCHs to EDs and its associations with ED length of stay, hospitalization duration, and unplanned ED revisits. On average, only 1.33 health information items were exchanged per transfer, with significantly higher rates from LTCHs (3.35 items) than LTCFs (0.04 items). Greater HIE correlated with shorter ED stays, highlighting its potential to enhance emergency care efficiency. However, no significant associations were observed between HIE and hospital length of stay or unplanned ED revisits, suggesting a need to explore other influencing factors. These findings highlight the urgent need for standardized transfer forms and structured HIE protocols in LTC settings to improve elderly patient outcomes. Policy-makers should prioritize establishing mandatory documentation practices to ensure patient safety and effective care coordination.

Notes

CONFLICTS OF INTEREST

The authors declared no conflict of interest.

AUTHORSHIP

Study conception and design acquisition - Kim HJ and Choi S; Data collection - Kim HJ; Data analysis & Interpretation - Kim HJ and Choi S; Drafting & Revision of the manuscript - Kim HJ and Choi S.

DATA AVAILABILITY

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Characteristics	Categories	Total	LTCHs (n=177)	LTCFs (n=275)
Characteristics	Categories	n (%) or M± SD	n (%) or M± SD	n (%) or M± SD
Age (year)		82.58±7.92	80.54±7.88	83.88±7.68
	65∼74	77 (17.0)	42 (23.7)	35 (12.7)
	75∼84	187 (41.4)	78 (44.1)	109 (39.6)
	≥85	188 (41.6)	57 (32.2)	131 (47.6)
Gender	Men	150 (33.2)	77 (43.5)	73 (26.5)
Gender	Women	302 (66.8)	100 (56.5)	202 (73.5)
Reason for ED visit	Illness	425 (94.0)	171 (96.6)	254 (92.4)
Reason for ED visit	Trauma	27 (6.0)	6 (3.4)	21 (7.6)
Level of consciousness	Alert	269 (59.5)	113 (63.8)	156 (56.7)
	Verbal response	79 (17.5)	32 (18.1)	47 (17.1)
	Painful response	88 (19.5)	30 (16.9)	58 (21.1)
	Unresponsive	16 (3.5)	2 (1.1)	14 (5.1)
Charlson comorbidity index		2.84±1.91	3.46±2.17	2.43±1.59
	0	28 (6.2)	12 (6.8)	16 (5.8)
	1	84 (18.6)	20 (11.3)	64 (23.3)
	2	119 (26.3)	31 (17.5)	88 (32.0)
	≥3	221 (48.9)	114 (64.4)	107 (38.9)
Outcomes of ED visit	Discharge	152 (33.6)	48 (27.1)	104 (37.8)
	Transfer	7 (1.5)	7 (4.0)	0 (0.0)
	Expire	15 (3.3)	0 (0.0)	15 (5.5)
	Admission	278 (61.5)	122 (68.9)	156 (56.7)
	Discharge	195 (70.1)	73 (59.9)	122 (78.2)
	Transfer	33 (11.9)	21 (17.2)	12 (7.7)
	AMAD	3 (1.1)	1 (0.8)	2 (1.3)
	Expire	47 (16.9)	27 (22.1)	20 (12.8)

HIE and health outcomes		Categories	Total	LTCHs (n=177)	LTCFs (n=275)	Z or x² (p)
HIE and health outcomes		Categories	n (%) or M± SD	n (%) or M± SD	n (%) or M± SD	Z or x² (p)
HIE	Total HIE		1.33±2.45	3.35±2.93	0.04±0.25	-13.81 (＜.001)
	Institution-related HIE	No	347 (76.8)	73 (41.2)	274 (99.6)	205.90 (＜.001)
		Yes	105 (23.2)	104 (58.8)	1 (0.4)
	Institution's name	Yes	105 (23.2)	104 (58.8)	1 (0.4)
	Institution's phone number	Yes	80 (17.7)	80 (45.2)	0 (0.0)
	Family member phone number	Yes	7 (1.5)	7 (4.0)	0 (0.0)
	Patient-related HIE	No	342 (75.7)	73 (41.2)	269 (97.8)	187.19 (＜.001)
		Yes	110 (24.3)	104 (58.8)	6 (2.2)
	Past medical history	Yes	106 (23.5)	104 (58.8)	2 (0.7)
	Transfer form	Yes	103 (22.8)	103 (58.2)	0 (0.0)
	Reason for transfer to ED	Yes	102 (22.6)	102 (57.6)	0 (0.0)
	Current medications	Yes	51 (11.3)	46 (26.0)	5 (1.8)
	Vital signs at time of complaint	Yes	26 (5.8)	24 (13.6)	2 (0.7)
	Laboratory data	Yes	11 (2.4)	11 (6.2)	0 (0.0)
	Communication ability	Yes	3 (0.7)	3 (1.7)	0 (0.0)
	AD for level of care and resuscitation	Yes	3 (0.7)	3 (1.7)	0 (0.0)
	Baseline cognitive function	Yes	2 (0.4)	2 (1.1)	0 (0.0)
	Mobility or basal ambulatory status	Yes	2 (0.4)	2 (1.1)	0 (0.0)
	ADL or usual functional status	Yes	1 (0.2)	1 (0.6)	0 (0.0)
	Allergy status	Yes	1 (0.2)	1 (0.6)	0 (0.0)
	Immunization status	Yes	0 (0.0)	0 (0.0)	0 (0.0)
	Bowel continence	Yes	0 (0.0)	0 (0.0)	0 (0.0)
	Bladder continence	Yes	0 (0.0)	0 (0.0)	0 (0.0)
	Nursing record	Yes	0 (0.0)	0 (0.0)	0 (0.0)
Health outcomes	ED length of stay, (hours)		235.04±245.76	211.76±173.84	250.01±281.84	-0.64 (.520)
	Hospital length of stay, (days) (n=278)		15.01±17.22	17.76±23.20	12.87±9.95	-1.74 (.082)
	Unexpected ED revisit, (times)		8 (1.8)	2 (1.1)	6 (2.2)	0.69^† (.490)

Variables		ED length of stay		Hospital length of stay (n=278)		Unexpected ED revisit
Variables		ρ (p)	z (p)^†	ρ (p)	z (p)^†	ρ (p)	z (p)^†
Total	Total HIE	-.160 (.001)	1.06 (.144)	.083 (.168)	-0.12 (.454)	.002 (.974)	0.71 (.240)
	Institution-related HIE	-.160 (.001)	0.81 (.208)	.071 (.238)	-0.12 (.451)	.009 (.853)	0.61 (.270)
	Patient-related HIE	-.153 (.001)	0.95 (.170)	.078 (.194)	-0.11 (.457)	-.001 (.988)	0.75 (.227)
CCI low comorbidity	Total HIE	-.115 (.081)		.067 (.437)		.036 (.584)
	Institution-related HIE	-.079 (.232)		.056 (.517)		.041 (.536)
	Patient-related HIE	-.112 (.089)		.063 (.468)		.035 (.596)
CCI high comorbidity	Total HIE	-.213 (.001)		.081 (.335)		-.031 (.650)
	Institution-related HIE	-.236 (＜.001)		.071 (.398)		-.017 (.807)
	Patient-related HIE	-.200 (.003)		.076 (.368)		-.036 (.599)