(Lindenauer et al., 2007)However, this produced multiple transfers due to the involvement of multiple providers via information and communication technologies ( ICT) not fully or partially interoperable or intercommunicable. and the system. (Spehar et al., 2005) In terms of communication, in fact, many SNFs still use fax and paper documents to document and communicate with other organizations and have delayed full implementation of EHR or ICT in due to limited capital and hardware/infrastructure for implementation. (Filipova, 2013) These trends may have accelerated the increased fragmentation of health care delivery and complicated the transition and coordination of care. Inconsistency in transition of care. Third, there is inconsistency in the transition of care and limited universality in the practices of each health care system.