Using Health Information Exchanges to Reduce Readmissions

When it comes to improving healthcare quality and saving costs, keeping patients from returning to the hospital unnecessarily is a big deal. Thankfully, there's a powerful tool that helps with this—Health Information Exchanges (HIEs). Even better, when combined with Admission, Discharge, and Transfer (ADT) feeds, HIEs can work like a charm to reduce hospital readmissions.

This article explores a research-based strategy to reduce readmissions through HIEs by subscribing to ADT feeds, automating care coordination for 24-hour outreach, and using real-time data to take swift action. We’ll walk through the evidence, implementation steps, and real-world examples to show you how this approach can improve patient outcomes and avoid unnecessary costs.

What Are Health Information Exchanges (HIEs)?

Health Information Exchanges (HIEs) are platforms that let doctors, hospitals, and clinics securely share patients' medical information electronically. This helps everyone involved in a person’s care to see the full picture.

Instead of piecing together patient histories from scratch, caregivers with access to an HIE can see past visits, medications, test results, and more—all in one place. This makes it easier to make informed decisions quickly and keep care consistent, especially when multiple providers are involved.

Why Reducing Readmissions Matters

Hospital readmissions are when a patient has to go back to the hospital within 30 days of being discharged. Not only can this be tough on the patient, but it also costs a lot of money.

The U.S. Centers for Medicare & Medicaid Services (CMS) penalizes hospitals with high readmission rates. So reducing avoidable readmissions isn’t just good for patients—it’s smart for hospitals too.

Thankfully, when HIEs are used correctly—with real-time data and thoughtful follow-up steps—they can be an answer to this challenge.

The Role of ADT Feeds and Real-Time Data

What Are ADT Feeds?

ADT stands for Admission, Discharge, and Transfer. These are automated alerts sent from hospitals that tell when and where a patient is admitted, discharged, or transferred to another facility. They’re fast notifications that keep care teams in the loop—kind of like getting a text when your patient checks into or out of a hospital.

Here’s why that matters:

Real-Time Updates: ADT alerts provide caregivers with instant information about a patient’s status.
Faster Follow-Up: Immediate alerts mean care coordinators can connect with patients shortly after discharge.
Improved Communication: ADT feeds help different providers work together easily for smoother transitions of care.

One report published by the Office of the National Coordinator (ONC) explains that these ADT alerts can help reduce avoidable emergency room visits and readmissions by giving health teams the chance to act quickly.

HIEs that integrate real-time ADT feeds allow providers to move from a reactive to a proactive approach. In fact, according to research from The American Journal of Managed Care, accessing HIE data within 30 days of discharge has been linked to a 57% reduction in readmission odds.

Auto-Tasking Coordinators for 24-Hour Outreach

Once an ADT alert is triggered, the next crucial step is to make sure someone follows up with the patient—fast! That’s where auto-tasking comes into play.

How This Works

As soon as the HIE receives an ADT feed, the system creates a task for a care coordinator.
That coordinator reaches out to the patient within 24 hours of discharge.
During this outreach, they use the HIE data to review past history, new medications, test results, and any instructions provided at discharge.

Think of it as an automated safety net. If a patient is sent home without enough medicine or follow-up instructions, the care coordinator can catch it early and fix it fast. This early check-in helps prevent small problems from turning into big ones.

Proof That It Works

Here are some standout stats:

A study on PHIX, a health exchange in El Paso, found that early outreach increased the average time to readmission from 99 days to 238 days—that’s 139 more days of being hospital-free.
At the University of Texas Medical Branch (UTMB success story), implementing coordinated care with ADT alerts led to a 14.5% reduction in hospital readmissions and $1.9 million in cost savings.
In another project from the ONC, hospitals saved over $605,000 annually by preventing readmissions using 24-hour follow-up care tied to ADT alerts (source).

Simply put, early outreach saves lives and money.

Acting on Real-Time Data

Automation is handy, but what matters most is how healthcare providers use the information.

What Coordinators Do with HIE Data

Medication Reconciliation: Coordinators check if patients are taking the right medications after discharge.
Care Planning: They look at patient history to see what kind of follow-up is needed.
Social Support: If a patient lacks transportation, food, or someone to help at home, action can be taken quickly.
Communication: Coordinators can bridge the gap between hospital care and primary care—like connecting patients to clinics for a post-discharge visit.

By acting promptly, providers can catch issues that might otherwise lead to another hospital visit.

Case Study: Paso del Norte HIE (PHIX)

PHIX integrates multiple hospitals, community clinics, and emergency departments in El Paso and nearby areas.

Because all this data lives in one spot, emergency room doctors can view a patient’s full record right away. The results?

53% decrease in emergency department readmissions
Smoother communication between care teams
Better decisions thanks to accurate, complete patient histories (read more)

Talk about teamwork making the dream work!

Evidence-Based Outcomes at a Glance

Let’s break down the numbers.

Metric	Improvement	Source
30-day readmission odds	57% reduction	AJMC
Average time to readmission	Increased by 139 days	Simbo.ai
Emergency department readmissions	53% lower	Simbo.ai
Cost savings	$1.9 million annually	UTMB
Cost savings (sample hospitals)	$605,000 annually	HealthIT.gov

These aren’t just stats—they're real results showing that the right HIE approach makes a measurable difference.

Implementation Blueprint: Making It Happen

Here’s a three-step blueprint healthcare organizations can follow.

1. Subscribe to ADT Feeds

Partner with a regional HIE (like Rochester RHIO or PHIX)
Set up the technical side to receive ADT notifications in real time
Ensure your EHR system can process those alerts and connect to workflows

2. Automate Tasking for 24-Hour Outreach

Use the incoming ADT feeds to automatically create tasks
Assign care coordinators based on patient needs (e.g., chronic conditions, social risks)
Use triggers to prompt phone calls or home visits within 24 hours

3. Train Teams to Act on Data

Teach coordinators how to use HIE data to review medication, test results, and visit notes
Build internal protocols for different patient scenarios (e.g., heart failure vs pneumonia)
Include social determinants as part of post-discharge planning

By following these steps, providers can build a smarter, more connected care system that supports patients through every step of recovery.

Overcoming Common HIE Challenges

Just like any new system, challenges may pop up. But with a little planning, you can handle them smoothly:

Interoperability: Make sure your EHR systems can talk to the HIE. Adding standard protocols like HL7 or FHIR can help.
Staff Training: Prepare care teams to understand and use HIE tools effectively.
Data Sharing Agreements: Set up partnership agreements between facilities and providers to ensure secure data access.

Once everyone is on the same page, things get easier from there.