Use of Push and Pull Health Information Exchange Technologies by Ambulatory Care Practices and the Impact on Potentially Avoidable Healthcare Utilization

Providers’ improved access to electronic patient information through health information exchange (HIE) is a national policy priority and a key infrastructure requirement for the U.S. healthcare system. Thanks to significant public investments, providers have access to different HIE approaches to meet their information needs.

A “pull” approach, or query-based HIE, aggregates data from multiple organizations into a longitudinal, comprehensive patient record that reflects a patient’s care from across the community. This approach is called “pull” because the acquisition of information from this patient record is initiated by the user. Pull HIE users have access to a consolidated view of patients’ demographic information, prior diagnoses, medication history, radiology reports and images, laboratory results, and discharge summaries from all participating providers.

The “push” model of HIE closely resembles the faxing of paper records between providers or sending patient information via email. In push, structured documents such as test results and clinical care documents (CCDs) are sent from one provider to others. The term “push” reflects the act of sharing patient information initiates with the sender. The process may be automated so that key events, like the posting of test results, a hospital admission, or emergency department visit triggers the push of information.

There is a lack of evidence on the effectiveness of using a push or pull approach to information exchange, and it is unknown which approach best fits the primary care setting. The research team examined primary care provider adoption and use of HIE technologies to gain an understanding on which approaches they use and how, and the respective approaches’ impact on healthcare utilization.

The specific aims of this research were as follows:

• Determine whether primary care providers use push and pull as complementary or alternative approaches to HIE. 
• Quantify the effect of push and pull HIE on potentially avoidable healthcare utilization. 

A cross-sectional study of adult patient encounters at three federally qualified health centers analyzed HIE usage associated with each encounter. Interviews with end users of the information were conducted to obtain additional insights on usage. A second study analyzed push or pull HIE adoption among a panel of providers and subsequent utilization of inpatient and emergency department services among Medicare patients.

The research team found that push and pull HIE are used as complementary approaches by primary care providers. Interview findings indicated that providers typically supplement pushed information made available in the electronic health record with pulled information from the HIE. This approach is a mechanism for providers to learn additional information about a patient’s health and healthcare, inform transitions of care, or to follow up in the case of abnormal test results. Furthermore, adoption of pull HIE was associated with a decrease in potentially avoidable hospitalization and readmissions. The study found that among a panel of providers and Medicare beneficiaries, providers that used pull HIE were associated with a 15% relative decrease in hospitalization and 1.2% decrease in readmissions. Push HIE adoption was not associated with change in hospitalization or readmissions.