(Lindenauer et al., 2007)However, this resulted in multiple steps due to the involvement of multiple providers via information and communications technologies (ICT) that were not fully or partially interoperable or intercommunicable. and system. (Spehar et al., 2005) In terms of communication, in fact, there were many SNFs that still used faxes and paper charts to document and communicate with other organizations and delayed the full implementation of EHR or ICT due to limited capital and 'hardware/hardware. infrastructure for implementation. (Filipova, 2013) These trends may have accelerated the further fragmentation of healthcare delivery and making care transition and coordination difficult. Inconsistency in care transition Third, there is inconsistency in care transition and limited universality across each health care practice.