Health Information Exchange Improves Identification Of Frequent Emergency Department Users

From "wading through treacle" to "making haste slowly": A comprehensive yet parsimonious model of drivers and challenges to implementing patient data sharing projects based on an EPaCCS evaluation and four pre-existing literature reviews

Conceptually, this study aimed to 1) identify the challenges and drivers encountered by England's Electronic Palliative Care Coordination System (EPaCCS) projects in the context of challenges and drivers in other projects on data sharing for individual care (also referred to as Health Information Exchange, HIE) and 2) organise them in a comprehensive yet parsimonious framework. The study also had a strong applied goal: to derive specific and non-trivial recommendations for advancing data sharing projects, particularly ones in early stages of development and implementation. Primary data comprised 40 in-depth interviews with 44 healthcare professionals, patients, carers, project team members and decision makers in Cambridgeshire, UK. Secondary data were extracted from four pre-existing literature reviews on Health Information Exchange and Health Information Technology implementation covering 135 studies. Thematic and framework analysis underpinned by "pluralist" coding were the main analytical approaches used. We reduced an initial set of >1,800 parameters into >500 challenges and >300 drivers to implementing EPaCCS and other data sharing projects. Less than a quarter of the 800+ parameters were associated primarily with the IT solution. These challenges and drivers were further condensed into an action-guiding, strategy-informing framework of nine types of "pure challenges", four types of "pure drivers", and nine types of "oppositional or ambivalent forces". The pure challenges draw parallels between patient data sharing and other broad and complex domains of sociotechnical or social practice. The pure drivers differ in how internal or external to the IT solution and project team they are, and thus in the level of control a project team has over them. The oppositional forces comprise pairs of challenges and drivers where the driver is a factor serving to resolve or counteract the challenge. The ambivalent forces are factors perceived simultaneously as a challenge and a driver depending on context, goals and perspective. The framework is distinctive in its emphasis on: 1) the form of challenges and drivers; 2) ambivalence, ambiguity and persistent tensions as fundamental forces in the field of innovation implementation; and 3) the parallels it draws with a variety of non-IT, non-health domains of practice as a source of fruitful learning. Teams working on data sharing projects need to prioritise further the shaping of social interactions and structural and contextual parameters in the midst of which their IT tools are implemented. The high number of "ambivalent forces" speaks of the vital importance for data sharing projects of skills in eliciting stakeholders' assumptions; managing conflict; and navigating multiple needs, interests and worldviews.

Impact of a Statewide Emergency Department Information Exchange on Health Care Use and Expenditures

OBJECTIVE

To assess the effects of a program mandating the statewide adoption of an emergency department information exchange (EDIE) on health care utilization and spending among Medicaid enrollees in Washington state.

DATA SOURCE

Medicaid claims and managed care encounters from the Washington Health Care Authority.

STUDY DESIGN

A difference-in-differences analysis with trends was used to compare changes in ED visits, inpatient admissions, primary care visits, and expenditures among frequent ED users (≥5 ED visits in past year) to those of infrequent users through the second year Washington's program.

DATA EXTRACTION

The study population included adult Medicaid enrollees with ED visits between January 2010-October 2014.

PRINCIPAL FINDINGS

There were 505,667 ED visits among 153,543 unique enrollees included in the analysis. Washington's program was associated with a small, but statistically significant differential change of -0.70 ED visits per enrollee per year (95% CI: -1.24, -0.16) in the first year after EDIE was mandated, or 8.2% of the baseline ED visit rate among frequent users. However, by the second year of implementation, these effects on ED use were no longer significant, nor were there any measurable effects on inpatient admissions, primary care use or expenditures in any period.

CONCLUSIONS

Statewide implementation of EDIE was associated with a small reduction in ED use among frequent users in the first year of the program but did not change overall spending or other utilization outcomes.

Impact of the COVID-19 Pandemic on Healthcare-Seeking Behaviors among Frequent Emergency Department Users: A Cohort Study

In 2020, Taiwan’s healthcare system faced a notable burden imposed by the coronavirus disease (COVID-19) pandemic. Emergency department (ED) is a high-risk area for severe acute respiratory syndrome coronavirus 2 transmission. The effect of COVID-19 on the utilization of ED services among frequent ED users remains unknown. This cohort study determined the impact of the COVID-19 pandemic on healthcare-seeking behaviors among frequent ED users at Taipei City Hospital, Taiwan. We included ED users aged ≥ 18 years admitted to Taipei City Hospital during February 2019–January 2020 (before the pandemic) and February 2020–January 2021 (during the pandemic). Frequent ED users were patients with four or more ED visits per year. Stepwise logistic regression was performed to identify predictors of frequent ED use during the COVID-19 pandemic. Frequent ED users had shorter hospital stays in the ED during the pandemic. After adjusting for sociodemographic factors and other covariates, patients with a triage status of level 4–5, pneumonia diagnosis, giddiness, or dyspnea were more likely frequent ED visitors during the COVID-19 pandemic. To reduce the risk of acquiring COVID-19, it is important to utilize territorial healthcare or telehealth to avoid inappropriate ED visits for patients with a low level of risk or chronic disease.

Leveraging a health information exchange to examine the accuracy of self-report emergency department utilization data among hospitalized injury survivors

Background

Accurate acute care medical utilization history is an important outcome for clinicians and investigators concerned with improving trauma center care. The objective of this study was to examine the accuracy of self-report emergency department (ED) utilization compared with utilization obtained from the Emergency Department Information Exchange (EDIE) in admitted trauma surgery patients with comorbid mental health and substance use problems.

Methods

This is a retrospective cohort study of 169 injured patients admitted to the University of Washington’s Harborview Level I Trauma Center. Patients had high levels of post-traumatic stress disorder and depressive symptoms, suicidal ideation and alcohol comorbidity. The investigation used EDIE, a novel health technology tool that collects information at the time a patient checks into any ED in Washington and other US states. Patterns of EDIE-documented visits were described, and the accuracy of injured patients’ self-report visits was compared with EDIE-recorded visits during the course of the 12 months prior to the index trauma center admission.

Results

Overall, 45% of the sample (n=76) inaccurately recalled their ED visits during the past year, with 36 participants (21%) reporting less ED visits than EDIE indicated and 40 (24%) reporting more ED visits than EDIE indicated. Patients with histories of alcohol use problems and major psychiatric illness were more likely to either under-report or over-report ED health service use.

Discussion

Nearly half of all patients were unable to accurately recall ED visits in the previous 12 months compared with EDIE, with almost one-quarter of patients demonstrating high levels of disagreement. The improved accuracy and ease of use when compared with self-report make EDIE an important tool for both clinical and pragmatic trial longitudinal outcome assessments. Orchestrated investigative and policy efforts could further examine the benefits of introducing EDIE and other information exchanges into routine acute care clinical workflows.

Level of evidence

II/III.

Trial registration number

ClinicalTrials.gov NCT02274688.

Evaluation of a Multidisciplinary Care Coordination Program for Frequent Users of the Emergency Department

PURPOSE OF STUDY

The purpose of this study was to evaluate the impact of a quality improvement multidisciplinary care coordination program designed to reduce frequent emergency department (ED) utilization and hospital admissions.

PRIMARY PRACTICE SETTING

The single hospital ED is part of a large, integrated, managed care delivery system in Northern California serving the city of Oakland, California.

METHODOLOGY AND SAMPLE

A retrospective cohort study design was used to analyze a multidisciplinary care coordination program on 58 patients during January 2015 and August 2018. Patients were identified from a high-utilization report when they had 10 or more ED visits in a 6-month period, were 18 years of age or older, and members of the integrated delivery system's health plan. Data were collected at initiation and 6 months postintervention. The pre-/postanalysis consisted of descriptive statistics, Wilcoxon signed ranks test, and binary logistic regression.

RESULTS

There was a statistically significant pre-/postdifference of 7.7 ED visits (95% confidence interval [CI] = 4.44-10.97, p < .001). The program did not result in statistically significant reduced hospital admissions (95% CI =-1.24 to 1.45, p = .875). Prior frequent use, number of pre-ED visits, age, sex, complex medical history, and mental health disorder had a significant effect on frequent ED use (χ[6] =17.62, p = .007, McFadden R = .32]. Sex (odds ratio [OR] = 5.13, p = .070), prior frequent use (OR = 2.87, p = .252), and complex medical history (OR = 2.52, p = .412) had the greatest odds of ongoing frequent ED use.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

We demonstrated reductions in ED use among frequent users with a low-cost care management intervention. Our multidisciplinary care coordination program confirms the positive impact case management has on utilization and health outcomes. We established that a care coordination program can optimize the overall quality of care and control hospital costs incurred by this vulnerable population. The effectiveness of this program contributes to the advancement of case management efforts in undertaking the challenging health care issue of reducing repeated visits by frequent users, a practice that strains emergency medical services.

Characteristics and predictors of adult frequent emergency department users in the United States: A systematic literature review

STUDY OBJECTIVE

We conducted a systematic literature review to identify and to update patient characteristics and contextual factors for adult frequent emergency department users (FEDUs) compared with non-FEDU in an era where the US health care system underwent substantial changes.

METHODS

We searched MEDLINE, CINAHL, and EMBASE to identify all relevant articles after 2010 through July 2018 that describe FEDU. We included US studies on adult FEDU only and excluded studies on specific subgroups of FEDU. We included demographic, clinical, and health care utilization information, and two reviewers independently evaluated the studies using the Joanna Briggs Institute Critical Appraisal tool.

RESULTS

The 11 studies included in the review indicated that FEDU were 4% to 16% of total ED users but accounted for 14% to 47% of ED visits, with six to nine visits per year on average. The majority of FEDU were young or middle-aged adults, females, of low socioeconomic status and high school or less education, with public insurance, multiple primary care provider visits, and chronic conditions. Fair or poor self-perceived health status, unemployment, unmet needs from primary care providers (PCPs), mental health, and substance abuse were predictors of FEDU.

CONCLUSION

FEDUs are disproportionally sicker and are also heavy users of non-ED health care service providers. The limited data for non-ED health services use in facility-specific studies of FEDU may contribute to findings in such studies that complex and unmet needs from PCPs contributed to ED visits. This suggests the need for more comprehensive data analysis beyond a few sites that can inform systemic management approaches.

Emergency Physician Use of the Alberta Netcare Portal, a Province-Wide Interoperable Electronic Health Record: Multi-Method Observational Study

Background

The adoption and use of an electronic health record (EHR) can facilitate real-time access to key health information and support improved outcomes. Many Canadian provinces use interoperable EHRs (iEHRs) to facilitate health information exchange, but the clinical use and utility of iEHRs has not been well described.

Objective

The aim of this study was to describe the use of a provincial iEHR known as the Alberta Netcare Portal (ANP) in 4 urban Alberta emergency departments. The secondary objectives were to characterize the time spent using the respective electronic tools and identify the aspects that were perceived as most useful by emergency department physicians.

Methods

In this study, we have included 4 emergency departments, 2 using paper-based ordering (University of Alberta Hospital [UAH] and Grey Nuns Community Hospital [GNCH]) and 2 using a commercial vendor clinical information system (Peter Lougheed Centre [PLC] and Foothills Medical Centre [FMC]). Structured clinical observations of ANP use and system audit logs analysis were compared at the 4 sites from October 2014 to March 2016.

Results

Observers followed 142 physicians for a total of 566 hours over 376 occasions. The median percentage of observed time spent using ANP was 8.5% at UAH (interquartile range, IQR, 3.7%-13.3%), 4.4% at GNCH (IQR 2.4%-4.4%), 4.6% at FMC (IQR 2.4%-7.6%), and 5.1% at PLC (IQR 3.0%-7.7%). By combining administrative and access audit data, the median number of ANP screens (ie, results and reports displayed on a screen) accessed per patient visit were 20 at UAH (IQR 6-67), 9 at GNCH (IQR 4-29), 7 at FMC (IQR 2-18), and 5 at PLC (IQR 2-14). When compared with the structured clinical observations, the statistical analysis of screen access data showed that ANP was used more at UAH than the other sites.

Conclusions

This study shows that the iEHR is well utilized at the 4 sites studied, and the usage patterns implied clinical value. Use of the ANP was highest in a paper-based academic center and lower in the centers using a commercial emergency department clinical information system. More study about the clinical impacts of using iEHRs in the Canadian context including longer term impacts on quality of practice and safety are required.

Predicting hospital admission at emergency department triage using machine learning

OBJECTIVE

To predict hospital admission at the time of ED triage using patient history in addition to information collected at triage.

METHODS

This retrospective study included all adult ED visits between March 2014 and July 2017 from one academic and two community emergency rooms that resulted in either admission or discharge. A total of 972 variables were extracted per patient visit. Samples were randomly partitioned into training (80%), validation (10%), and test (10%) sets. We trained a series of nine binary classifiers using logistic regression (LR), gradient boosting (XGBoost), and deep neural networks (DNN) on three dataset types: one using only triage information, one using only patient history, and one using the full set of variables. Next, we tested the potential benefit of additional training samples by training models on increasing fractions of our data. Lastly, variables of importance were identified using information gain as a metric to create a low-dimensional model.

RESULTS

A total of 560,486 patient visits were included in the study, with an overall admission risk of 29.7%. Models trained on triage information yielded a test AUC of 0.87 for LR (95% CI 0.86-0.87), 0.87 for XGBoost (95% CI 0.87-0.88) and 0.87 for DNN (95% CI 0.87-0.88). Models trained on patient history yielded an AUC of 0.86 for LR (95% CI 0.86-0.87), 0.87 for XGBoost (95% CI 0.87-0.87) and 0.87 for DNN (95% CI 0.87-0.88). Models trained on the full set of variables yielded an AUC of 0.91 for LR (95% CI 0.91-0.91), 0.92 for XGBoost (95% CI 0.92-0.93) and 0.92 for DNN (95% CI 0.92-0.92). All algorithms reached maximum performance at 50% of the training set or less. A low-dimensional XGBoost model built on ESI level, outpatient medication counts, demographics, and hospital usage statistics yielded an AUC of 0.91 (95% CI 0.91-0.91).

CONCLUSION

Machine learning can robustly predict hospital admission using triage information and patient history. The addition of historical information improves predictive performance significantly compared to using triage information alone, highlighting the need to incorporate these variables into prediction models.

Improving performance in the ED through laboratory information exchange systems

Background

The accessibility of laboratory test results is crucial to the performance of emergency departments and to the safety of patients. This study aims to develop a better understanding of which laboratory information exchange (LIE) systems emergency care physicians (ECPs) are using to consult their patients’ laboratory test results and which benefits they derive from such use.

Methods

A survey of 163 (36%) ECPs in Quebec was conducted in collaboration with the Quebec’s Department of Health and Social Services. Descriptive statistics, chi-square tests, cluster analyses, and ANOVAs were conducted.

Results

The great majority of respondents indicated that they use several LIE systems including interoperable electronic health record (iEHR) systems, laboratory results viewers (LRVs), and emergency department information systems (EDIS) to consult their patients’ laboratory results. Three distinct profiles of LIE users were observed. The extent of LIE usage was found to be primarily determined by the functional design differences between LIE systems available in the EDs. Our findings also indicate that the more widespread LIE usage, the higher the perceived benefits. More specifically, physicians who make extensive use of iEHR systems and LRVs obtain the widest range of benefits in terms of efficiency, quality, and safety of emergency care.

Conclusions

Extensive use of LIE systems allows ECPs to better determine and monitor the health status of their patients, verify their diagnostic assumptions, and apply evidence-based practices in laboratory medicine. But for such benefits to be possible, ECPs must be provided with LIE systems that produce accurate, up-to-date, complete, and easy-to-interpret information.

Case Management Reduces Length of Stay, Charges, and Testing in Emergency Department Frequent Users

Introduction

Case management is an effective, short-term means to reduce emergency department (ED) visits in frequent users of the ED. This study sought to determine the effectiveness of case management on frequent ED users, in terms of reducing ED and hospital length of stay (LOS), accrued costs, and utilization of diagnostic tests.

Methods

The study consisted of a retrospective chart review of ED and inpatient visits in our hospital's ED case management program, comparing patient visits made in the one year prior to enrollment in the program, to the visits made in the one year after enrollment in the program. We examined the LOS, use of diagnostic testing, and monetary charges incurred by these patients one year prior and one year after enrollment into case management.

Results

The study consisted of 158 patients in case management. Comparing the one year prior to enrollment to the one year after enrollment, ED visits decreased by 49%, inpatient admissions decreased by 39%, the use of computed tomography imaging decreased 41%, the use of ultrasound imaging decreased 52%, and the use of radiographs decreased 38%. LOS in the ED and for inpatient admissions decreased by 39%, reducing total LOS for these patients by 178 days. ED and hospital charges incurred by these patients decreased by 5.8 million dollars, a 41% reduction. All differences were statistically significant.

Conclusion

Case management for frequent users of the ED is an effective method to reduce patient visits, the use of diagnostic testing, length of stay, and cost within our institution.

Predicting frequent emergency department visits among children with asthma using EHR data

OBJECTIVE

For children with asthma, emergency department (ED) visits are common, expensive, and often avoidable. Though several factors are associated with ED use (demographics, comorbidities, insurance, medications), its predictability using electronic health record (EHR) data is understudied.

METHODS

We used a retrospective cohort study design and EHR data from one center to examine the relationship of patient factors in 1 year (2013) and the likelihood of frequent ED use (≥2 visits) in the following year (2014), using bivariate and multivariable statistics. We applied and compared several machine-learning algorithms to predict frequent ED use, then selected a model based on accuracy, parsimony, and interpretability.

RESULTS

We identified 2691 children. In bivariate analyses, future frequent ED use was associated with demographics, co-morbidities, insurance status, medication history, and use of healthcare resources. Machine learning algorithms had very good AUC (area under the curve) values [0.66-0.87], though fair PPV (positive predictive value) [48-70%] and poor sensitivity [16-27%]. Our final multivariable logistic regression model contained two variables: insurance status and prior ED use. For publicly insured patients, the odds of frequent ED use were 3.1 [2.2-4.5] times that of privately insured patients. Publicly insured patients with 4+ ED visits and privately insured patients with 6+ ED visits in a year had ≥50% probability of frequent ED use the following year. The model had an AUC of 0.86, PPV of 56%, and sensitivity of 23%.

CONCLUSION

Among children with asthma, prior frequent ED use and insurance status strongly predict future ED use.

CARES: A Community-wide Collaboration Identifies Super-utilizers and Reduces Their 9-1-1 Call, Emergency Department, and Hospital Visit Rates

BACKGROUND

A subset of individuals who inefficiently and frequently use emergency department (ED) services are called "super-utilizers." Our healthcare system is fragmented and complex, making it difficult for providers to identify super-utilizers and address their wide range of health issues.

OBJECTIVE

The objective of our study was to evaluate a novel community-wide collaboration program called CARES (Community Assistance Referral and Education Services) designed to identify super-utilizers through local partnering organizations. CARES assists patients in developing their personal health and wellness goals, and navigates them away from 9-1-1 calls, emergency room visits, and hospital admissions, and toward more appropriate resources over 90 days.

METHODS

This was a retrospective observational analysis of the CARES program. Data were collected from March 2013 to December 2015. The study population included: enrolled adults with non-compliance of medication or treatment; behavioral health problems; multiple 9-1-1 responses in a short period of time; three or more ED visits within six months; patients with multiple hospital admissions. Adults who were outside of the study period or had missing outcome information were excluded. The primary outcomes of this study were the median rate of 9-1-1 calls/month/person, ED and hospital visits/month/person. Wilcoxon rank-sum tests were used to compare changes between pre- vs. post-enrollment for each subject.

RESULTS

A total of 441 subjects were included in this study. The majority of patients (64%) were female, 64% were white, and the median (IQR) age was 48 (35-62) years old. A total of 51% were on Medicaid and 69% identified behavioral health issues as their barriers to optimal health care. Between pre- and post-enrollment periods, the median (IQR) monthly rate of 9-1-1 calls, ED visits, and hospital admissions significantly decreased by 0.26 (-0.06, 0.90), 0.25 (-0.08, 0.71), and 0.18 (0.04, 0.53) (p < 0.001 for all).

CONCLUSIONS

When health systems in a geographic area share data, they are better able to recognize patterns of overuse, and address them properly. This study demonstrated that a collaborative 90-day intervention identifying super-utilizers reduced the monthly rate of 9-1-1 calls, ED visits, and hospital admissions.

A Comprehensive View of Frequent Emergency Department Users Based on Data from a Regional HIE

OBJECTIVES

A small but significant number of patients make frequent emergency department (ED) visits to multiple EDs within a region. We have a unique health information exchange (HIE) that includes every ED encounter in all hospital systems in our region. Using our HIE we were able to characterize all frequent ED users in our region, regardless of hospital visited or payer class. The objective of our study was to use data from an HIE to characterize patients in a region who are frequent ED users (FEDUs).

METHODS

We constructed a database from a cohort of adult patients (18 years old or older) with information in a regional HIE for a 1-year period beginning in April 2012. Patients were defined as FEDUs (those who made four or more visits during the study period) and non-FEDUs (those who made fewer than four ED visits during the study period). Predictor variables included age, race, sex, payer class, county of residence, and International Classification of Diseases, Ninth Revision codes. Bivariate (χ(2)) and multivariate (logistic regression) analyses were performed to determine associations between predictor variables and the outcome of being a FEDU.

RESULTS

The database contained 127,672 patients, 12,293 (9.6%) of whom were FEDUs. Logistic regression showed the following patient characteristics to be significantly associated with the outcome of being a FEDU: age 35 to 44 years; African American race; Medicaid, Medicare, and dual-pay payer class; and International Classification of Diseases, Ninth Revision codes 630 to 679 (complications of pregnancy, childbirth, and puerperium), 780 to 799 (ill-defined conditions), 280 to 289 (diseases of the blood), 290-319 (mental disorders), 680 to 709 (diseases of the skin and subcutaneous tissue), 710 to 739 (musculoskeletal and connective tissue disease), 460 to 519 (respiratory disease), and 520 to 579 (digestive disease). No significant differences were noted between men and women.

CONCLUSIONS

Data from an HIE can be used to describe all of the patients within a region who are FEDUs, regardless of the hospital system they visited. This information can be used to focus care coordination efforts and link appropriate patients to a medical home. Future studies can be designed to learn the reasons why patients become FEDUs, and interventions can be developed to address deficiencies in health care that result in frequent ED visits.

San Francisco children living in redeveloped public housing used acute services less than children in older public housing

Understanding the links between housing and health is increasingly important. Poor housing quality is a predictor of poor health and developmental problems in low-income children. We examined associations between public housing type and recurrent pediatric emergency and urgent care hospital visits. Children ages 0-18 with public insurance who sought emergency care from any of three large medical systems in San Francisco were categorized by whether they lived in public housing redeveloped through the federal HOPE VI program, nonredeveloped public housing, or nonpublic housing in a census tract that also contained public housing. After we adjusted for potential confounding characteristics, we found that children living in nonredeveloped public housing were 39 percent more likely to have one or more repeat visits within one year for acute health care services unrelated to the initial visit, compared to children who lived in redeveloped HOPE VI housing. We observed no differences in repeat visits between children in redeveloped HOPE VI housing and those in nonpublic housing. These findings support the continued redevelopment of public housing as a means of both improving the health of vulnerable high-risk children from low-income neighborhoods and reducing health care costs.

Patients' Use of Multiple Hospitals in a Major US City: Implications for Population Management

Understanding how often patients seek care from multiple hospitals is important for care of individuals and populations, but it is not routinely measured because of lack of data. This study used data from a health information exchange (HIE) to measure the frequency with which patients seek care from multiple hospitals. This was a retrospective cohort study (2010-2011) of all patients who sought emergency department (ED) or inpatient care at 6 participating hospitals in Manhattan. The study found that all 6 hospitals shared patients with each of the other hospitals and that 10.0% of all ED visits and 9.1% of all admissions were for patients who had been seen in a different hospital in the past 12 months. Patients are frequently seen by multiple hospitals, which poses a challenge for clinical care and population management. By capturing which patients are seen where and when, HIEs are well suited for facilitating population management.

Increased Identification of Emergency Department 72-hour Returns Using Multihospital Health Information Exchange

OBJECTIVES

Emergency departments (EDs) commonly analyze cases of patients returning within 72 hours of initial ED discharge as potential opportunities for quality improvement. In this study, we tested the use of a health information exchange (HIE) to improve identification of 72-hour return visits compared to individual hospitals' site-specific data.

METHODS

We collected deidentified patient data over a 5-year study period from Healthix, an HIE in the New York metropolitan area. We measured site-specific 72-hour ED returns and compared these data to those obtained from a regional 31-site HIE (Healthix) and to those from a smaller, antecedent 11-site HIE. Although only ED visits were counted as index visits, either ED or inpatient revisits within 72 hours of the index visit were considered as early returns.

RESULTS

A total of 12,669,657 patient encounters were analyzed across the 31 HIE EDs, including 6,352,829 encounters from the antecedent 11-site HIE. Site-specific 72-hour return visit rates ranged from 1.1% to 15.2% (median = 5.8%) among the individual 31 sites. When the larger HIE was used to identify return visits to any site, individual EDs had a 72-hour return frequency of 1.8% to 15.5% (median = 6.8%). HIE increased the identification ability of 72-hour ED return analyses by a mean of 11.16% (95% confidence interval = 11.10% to 11.22%) compared with site-specific (no HIE) analyses.

CONCLUSION

This analysis demonstrates incremental improvements in our ability to identify early ED returns using increasing levels of HIE data aggregation. Although intuitive, this has not been previously described using HIE. ED quality measurement and patient safety efforts may be aided by using HIE in 72-hour return analyses.

Integrating care for frequent users of emergency departments: implementation evaluation of a brief multi-organizational intensive case management intervention

Background

Addressing the needs of frequent users of emergency departments (EDs) is a health system priority in many jurisdictions. This study describes stakeholder perspectives on the implementation of a multi-organizational brief intervention designed to support integration and continuity of care for frequent ED users with mental health and addictions problems, focusing on perceived barriers and facilitators to early implementation in a large urban centre.

Methods

Coordinating Access to Care from Hospital Emergency Departments (CATCH-ED) is a brief case management intervention bridging hospital, primary and community care for frequent ED users experiencing mental illness and addictions. To examine barriers and facilitators to early implementation of this multi-organizational intervention, between July and October 2012, 47 stakeholders, including direct service providers, managers and administrators participated in 32 semi-structured qualitative interviews and one focus group exploring their experience with the intervention and factors that helped or hindered successful early implementation. Qualitative data were analyzed using thematic analysis.

Results

Stakeholders valued the intervention and its potential to support continuity of care for this population. Service delivery system factors, including organizational capacity and a history of collaborative relationships across the healthcare continuum, and support system factors, such as training and supervision, emerged as key facilitators of program implementation. Operational challenges included early low program referral rates, management of a multi-organizational initiative, variable adherence to the model among participating organizations, and scant access to specialty psychiatric resources. Factors contributing to these challenges included lack of dedicated staff in the ED and limited local system capacity to support this population, and insufficient training and technical assistance available to participating organizations.

Conclusions

A multi-organizational brief intervention is an acceptable model to support integration of hospital, primary and community care for frequent ED users. The study highlights the importance of early implementation evaluation to identify potential solutions to implementation barriers that may be applicable to many jurisdictions.

Outcomes From Health Information Exchange: Systematic Review and Future Research Needs

BACKGROUND

Health information exchange (HIE), the electronic sharing of clinical information across the boundaries of health care organizations, has been promoted to improve the efficiency, cost-effectiveness, quality, and safety of health care delivery.

OBJECTIVE

To systematically review the available research on HIE outcomes and analyze future research needs.

METHODS

Data sources included citations from selected databases from January 1990 to February 2015. We included English-language studies of HIE in clinical or public health settings in any country. Data were extracted using dual review with adjudication of disagreements.

RESULTS

We identified 34 studies on outcomes of HIE. No studies reported on clinical outcomes (eg, mortality and morbidity) or identified harms. Low-quality evidence generally finds that HIE reduces duplicative laboratory and radiology testing, emergency department costs, hospital admissions (less so for readmissions), and improves public health reporting, ambulatory quality of care, and disability claims processing. Most clinicians attributed positive changes in care coordination, communication, and knowledge about patients to HIE.

CONCLUSIONS

Although the evidence supports benefits of HIE in reducing the use of specific resources and improving the quality of care, the full impact of HIE on clinical outcomes and potential harms are inadequately studied. Future studies must address comprehensive questions, use more rigorous designs, and employ a standard for describing types of HIE.

TRIAL REGISTRATION

PROSPERO Registry No CRD42014013285; http://www.crd.york.ac.uk/PROSPERO/ display_record.asp?ID=CRD42014013285 (Archived by WebCite at http://www.webcitation.org/6dZhqDM8t).

The prehospital and hospital costs of emergency care for frequent ED patients

INTRODUCTION

Frequent emergency department (ED) use has been identified as a cause of ED overcrowding and increasing health care costs. Studies have examined the expense of frequent patients (FPs) to hospitals but have not added the cost Emergency Medical Services (EMS) to estimate the total cost of this pattern of care.

METHODS

Data on 2012 ED visits to a rural Level I Trauma Center and public safety net hospital were collected through a deidentified patient database. Transport data and 2012 Medicare Reimbursement Schedules were used to estimate the cost of EMS transport. Health information, outcomes, and costs were compared to find differences between the FP and non-FP group.

RESULTS

This study identified 1242 FPs who visited the ED 5 or more times in 2012. Frequent patients comprised 3.25% of ED patients but accounted for 17% of ED visits and 13.7% of hospital costs. Frequent patients had higher rates of chronic disease, severity scores, and mortality. Frequent patients arrived more often via ambulance and accounted for 32% of total transports at an estimated cost of $2.5-$3.2 million. Hospital costs attributable to FPs were $29.1 million, bringing the total cost of emergency care to $31.6-$32.3 million, approximately $25,000 per patient.

CONCLUSIONS

This study demonstrates that the inclusion of a prehospital cost estimate adds approximately 10% to the cost of care for the FP population. In addition to improving care for a sick population of patients, programs that reduce frequent EMS and ED use have the potential to produce a favorable cost benefit to communities and health systems.

Predicting frequent ED use by people with epilepsy with health information exchange data

OBJECTIVES

To describe (1) the predictability of frequent emergency department (ED) use (a marker of inadequate disease control and/or poor access to care), and (2) the demographics, comorbidities, and use of health services of frequent ED users, among people with epilepsy.

METHODS

We obtained demographics, comorbidities, and 2 years of encounter data for 8,041 people with epilepsy from a health information exchange in New York City. Using a retrospective cohort design, we explored bivariate relationships between baseline characteristics (year 1) and subsequent frequent ED use (year 2). We then built, evaluated, and compared predictive models to identify frequent ED users (≥4 visits year 2), using multiple techniques (logistic regression, lasso, elastic net, CART [classification and regression trees], Random Forests, AdaBoost, support vector machines). We selected a final model based on performance and simplicity.

RESULTS

People with epilepsy who, in year 1, were adults (rather than children or seniors), male, Manhattan residents, frequent users of health services, users of multiple health systems, or had medical, neurologic, or psychiatric comorbidities, were more likely to frequently use the ED in year 2. Predictive techniques identified frequent ED visitors with good positive predictive value (approximately 70%) but poor sensitivity (approximately 20%). A simple strategy, selecting individuals with 11+ ED visits in year 1, performed as well as more sophisticated models.

CONCLUSIONS

People with epilepsy with 11+ ED visits in a year are at highest risk of continued frequent ED use and may benefit from targeted intervention to avoid preventable ED visits. Future work should focus on improving the sensitivity of predictions.

Health Information Exchange in Emergency Medicine

Emergency physicians often must make critical, time-sensitive decisions with a paucity of information with the realization that additional unavailable health information may exist. Health information exchange enables clinician access to patient health information from multiple sources across the spectrum of care. This can provide a more complete longitudinal record, which more accurately reflects the way most patients obtain care: across multiple providers and provider organizations. This information article explores various aspects of health information exchange that are relevant to emergency medicine and offers guidance to emergency physicians and to organized medicine for the use and promotion of this emerging technology. This article makes 5 primary emergency medicine-focused recommendations, as well as 7 additional secondary generalized recommendations, to health information exchanges, policymakers, and professional groups, which are crafted to facilitate health information exchange's purpose and demonstrate its value.

Early efforts to target and enroll high-risk diabetic patients into urban community-based programs

Health care disparities in minority populations can be attributed to a number of factors, including lack of access to coordinated primary care and chronic disease management programming. Interventions using a data-centric, coordinated, multidisciplinary, team-based approach to address patients with complex chronic comorbidities have demonstrated improvements in patient outcomes. The use of hospital admission and billing data coupled with care management teams to care for high-risk patients with chronic conditions may be an effective model for improving quality of care while reducing health care costs. This article describes how Camden city, the poorest city in the nation, has made headway toward developing an integrated approach to improving care while reducing costs for the city's most vulnerable.

Patients who use multiple EDs: quantifying the degree of overlap between ED populations

Introduction

The degree to which individual patients use multiple emergency departments (EDs) is not well-characterized. We determined the degree of overlap in ED population between three geographically proximate hospitals.

Methods

This retrospective cohort study reviewed administrative hospital records from 2003 to 2007 for patients registered to receive ED services at an urban academic, urban community, and suburban community ED located within 10 miles of one another. We determined the proportion who sought care at multiple EDs and secondarily characterized patterns of repeat encounters.

Results

There were 795,176 encounters involving 282,903 patients. There were 89,776 (31%) patients with multiple encounters to a single ED and 39,920 (14%) patients who sought care from multiple EDs. The 39,920 patients who sought care from multiple EDs generated 185,629 (23%) of all encounters. Patients with repeat encounters involving multiple EDs were more likely to be frequent or highly frequent users (30%) than patients with multiple encounters to a single ED (14%).

Conclusion

While only 14% of patients received care from more than one ED, they were responsible for a quarter of ED encounters. Patients who use multiple EDs are more often frequent or highly frequent users than are repeat ED visitors to the same ED. Overlap between ED populations is sufficient to warrant consideration by multiple domains of research, practice, and policy.

The visit-data warehouse: enabling novel secondary use of health information exchange data

INTRODUCTION/OBJECTIVES

Health Information Exchange (HIE) efforts face challenges with data quality and performance, and this becomes especially problematic when data is leveraged for uses beyond primary clinical use. We describe a secondary data infrastructure focusing on patient-encounter, nonclinical data that was built on top of a functioning HIE platform to support novel secondary data uses and prevent potentially negative impacts these uses might have otherwise had on HIE system performance.

BACKGROUND

HIE efforts have generally formed for the primary clinical use of individual clinical providers searching for data on individual patients under their care, but many secondary uses have been proposed and are being piloted to support care management, quality improvement, and public health.

DESCRIPTION OF THE HIE AND BASE INFRASTRUCTURE

This infrastructure review describes a module built into the Healthix HIE. Healthix, based in the New York metropolitan region, comprises 107 participating organizations with 29,946 acute-care beds in 383 facilities, and includes more than 9.2 million unique patients. The primary infrastructure is based on the InterSystems proprietary Caché data model distributed across servers in multiple locations, and uses a master patient index to link individual patients' records across multiple sites. We built a parallel platform, the "visit data warehouse," of patient encounter data (demographics, date, time, and type of visit) using a relational database model to allow accessibility using standard database tools and flexibility for developing secondary data use cases. These four secondary use cases include the following: (1) tracking encounter-based metrics in a newly established geriatric emergency department (ED), (2) creating a dashboard to provide a visual display as well as a tabular output of near-real-time de-identified encounter data from the data warehouse, (3) tracking frequent ED users as part of a regional-approach to case management intervention, and (4) improving an existing quality improvement program that analyzes patients with return visits to EDs within 72 hours of discharge.

RESULTS/LESSONS LEARNED

Setting up a separate, near-real-time, encounters-based relational database to complement an HIE built on a hierarchical database is feasible, and may be necessary to support many secondary uses of HIE data. As of November 2014, the visit-data warehouse (VDW) built by Healthix is undergoing technical validation testing and updates on an hourly basis. We had to address data integrity issues with both nonstandard and missing HL7 messages because of varied HL7 implementation across the HIE. Also, given our HIEs federated structure, some sites expressed concerns regarding data centralization for the VDW. An established and stable HIE governance structure was critical in overcoming this initial reluctance.

CONCLUSIONS

As secondary use of HIE data becomes more prevalent, it may be increasingly necessary to build separate infrastructure to support secondary use without compromising performance. More research is needed to determine optimal ways of building such infrastructure and validating its use for secondary purposes.

Enhancing a geriatric emergency department care coordination intervention using automated health information exchange-based clinical event notifications

Purpose:

In a health care system where patients often have numerous providers and multiple chronic medical conditions, interoperability of health information technology (HIT) is of paramount importance. Regional health information organizations (RHIO) often provide a health information exchange (HIE) as a solution, which gives stakeholders access to clinical data that they otherwise would not otherwise have. A secondary use of preexisting HIE infrastructure is clinical event notification (CEN) services, which send automated notifications to stakeholders. This paper describes the development and implementation of a CEN service enabled by a RHIO in the New York metropolitan area to improve care coordination for patients enrolled in a geriatric emergency department care coordination program.

Innovation:

This operational CEN system incorporates several innovations that to our knowledge have not been implemented previously. They include the near real-time notifications and the delivery of notifications via multiple pathways: electronic health record (EHR) “in-baskets,” email, text message to internet protocol-based “zone” phones, and automated encounter entry into the EHR. Based on these alerts the geriatric care coordination team contacts the facility where the patient is being seen and offers additional information or assistance with disposition planning with the goal of decreasing potentially avoidable admissions and duplicate testing.

Findings:

During the nearly one-year study period, the CEN program enrolled 5722 patients and sent 497 unique notifications regarding 206 patients. Of these notifications, 219 (44%) were for emergency department (ED) visits; 121 (55%) of those notifications were received during normal business hours when the care coordination team was available to contact the ED where the patient was receiving care. Hospital admissions resulted from 45% of ED visits 17.8% of these admissions lasted 48 hours or less, suggesting some might potentially be avoidable.

Conclusions and Discussion:

This study demonstrates the potential of CEN systems to improve care coordination by notifying providers of the occurrence of specific events. Although it could not directly be demonstrated here, we believe that widespread use of CEN systems have potential to reduce potentially avoidable admissions and duplicate testing, likely leading to decreased costs.