Before Electronic Health Records (EHRs) were widespread, politicians said we needed them so that when we are in an Emergency Department (ED), clinicians will have our health information available. Today, most hospitals and clinics use EHRs, but it’s been more difficult than expected to make your health information available in an emergency. The American College of Emergency Physicians (ACEP) Council investigated health information exchanges and made recommendations to improve the information available and the manner in which it is presented to facilitate better ED care and lower overall healthcare costs.
What electronic health information is needed in the ED. Although traditional healthcare documentation usually focuses on a specific point in time, the task of putting together important health information about an individual’s health journey, a longitudinal health record, is now happening. This is especially true of patients with ongoing health concerns, such as diabetes or heart failure. In addition, more care is provided outside the hospital, relying on patients and family members to handle complex care regimens that often result in unexpected complications. Patients may experience intolerable pain, severe vomiting and diarrhea, inability to eat, a fall due to weakness, respiratory distress, and require urgent attention that their regular clinic cannot address. They will go to an ED whose clinicians may not be able to access information in a timely and usable way. [1]
The information that’s not available could help patients avoid hospital admissions, and this is increasingly seen as important to containing healthcare costs. [2] In addition to contributing to increased costs, patients, especially older patients, can lose substantial muscle mass and function [3] and expose them to risks they would not encounter outside the hospital. [4] In either case, patients are better off if they can avoid time in the hospital.
Why it’s hard to get the right electronic health information to the ED. Patients often have more than one physician, especially if they have chronic, complex medical conditions, and they may have been to a hospital or surgery center in the recent past as well. For example, a patient may have adverse effects of a newly prescribed medication or a blood clot in a leg vein or elsewhere after surgery. Clinicians can provide better or more timely care if they have access to historical medical information.
In some cases it may be that too much information is presented to ED clinicians, if it isn’t formatted so that care can be provided efficiently. If obtaining information is complicated, and then when the information is delivered, it’s contained in pages and pages of text, frustration keeps it from being utilized in the way it could otherwise be used. In addition, confidence in patient-matching needs to be strengthened so that clinicians can be sure that the data they’re looking at reflects the past or current condition of the patient in front of them. This is a critical step to progress from “population health” practices, which have little impact on a patient in the ED, to “personalized medicine” which is what ED care is all about. [5]
ACEP’s recommendations. Their recommendations address foundational conditions necessary for making Health Information Exchange (HIE) work for patients and clinicians in the ED setting:
- ED concerns must be addressed when developing robust HIE technology and practices.
- Usable data standards must be developed and implemented.
- The ED user interface and workflow needs must be a high priority.
- Care standards must include information sharing, emphasizing actionable information.
In addition, secondary recommendations emphasize building awareness and developing practical approaches to sharing information – which may include data that today are not easily available via HIE, such as specialty-specific data. [6]
What type of exchange will facilitate this kind of data sharing? ACEP describes three types of information exchange: query-based; direct protocol-enabled; and consumer-mediated. [7] Datuit can support all of these, but is most involved in consumer-mediated HIE. The following addresses how it can enable ACEP’s recommendations.
As many of us remember, EHRs and HIE were sold as something that would help patients in emergency situations, much like “medical alert” bracelets or a packet of information on a refrigerator does. [8] Perhaps the time has come for patients to have their health data up-to-date and accurate, much as they do with financial data. [9] Efforts have started to bring patients into the health information loop with the Open Notes project finding success for both patients and clinicians. [10] With patients seeing more clinicians in multiple health systems, putting that information in a usable format would help patients, family caregivers who often help loved ones understand their problems and implement care plans, and various clinicians who need to work together, including ED clinicians.In that way, patients can “actively participate in their care coordination by furnishing other providers with their health information, identifying and correcting wrong or missing health information…and tracking and monitoring their own health.” [11]
In addition, by separating health data from the applications, various clinicians with different needs and patients and family caregivers can have different views of the information that work best for them. It has become obvious to many that the way data is presented to one user will not necessarily be useful to another user, and that there are many clinicians and others who need to interact with health data than were initially envisioned. For example, HIE between hospitals and clinics and primary care clinics and specialty clinics was anticipated, yet lack of data sharing with long term care and behavioral health providers enables fragmented patient care. Enlarging the circle to include them, as well as dentists, pharmacists and others creates even more complexity and difficulty sharing data across systems. Datuit is working to make patient-centered data storage more commonplace with the ability to share that information with others safe, simple and secure.
[1] Shapiro JS, et al. Health Information Exchange in Emergency Medicine. Ann Emerg Med. Published online July 28, 2015. Accessed at http://www.annemergmed.com/article/S0196-0644(15)00524-7/abstract (subscription required). “Patient Crossover” and “Information Fragmentation” are commonly-encountered barriers to obtaining information and lead to poorer care and higher cost than if that information had been readily available. Pages 2-3.
[2] Ibid., page 3. Fewer repeated laboratory and imaging tests are also anticipated with better information availability.
[3] English KL and Paddon-Jones D. Protecting muscle mass and function in older adults during bed rest. Curr Opin Clin Nutr Metab Care 13(1):34-9 (2010). Accessed at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3276215/pdf/nihms-181019.pdf.
[4] Perla RJ, et al. Whole-Patient Measure of Safety: Using Administrative Data to Assess the Probability of Highly Undesirable Events During Hospitalization. Journal of Healthcare Quality 35(5):20-31 (2013). Accessed at http://onlinelibrary.wiley.com/doi/10.1111/jhq.12027/abstract (subscription required).
[5] Baum S. Is healthcare facing a battle of population health vs personalized medicine? MedCity News (November 5, 2013). Accessed at http://medcitynews.com/2013/11/healthcare-facing-battle-population-health-vs-personalized-health/.
[6] Supra., Note 1, page 9.
[7] Ibid., page 4.
[8] Brouhard R. Where should I leave medical information? About.com (March 7, 2014). Paramedics look for information when they are called to a home with an unresponsive patient. Accessed at http://firstaid.about.com/od/emergencypreparation/f/07_fridge_info.htm.
[9] Supra., Note 1, page 4.
[10] Wong V. Sharing Inpatient Progress Notes with Patients and Families: An Open Notes Pilot. Datuit Blog Post (May 26, 2014). Accessed at http://www.datuit.com/blog/entry/sharing_inpatient_progress_notes_with_patients_and_families.
[11] Supra., Note 1, page 4, citing the Office of the National Coordinator Website. Accessed at http://www.healthit.gov/providers-professionals/health-information-exchange/what-hie#consumer-mediated_exchange