If you’re looking for doctors who are enthusiastic about health information technology, you often need look no further than hospital emergency rooms.
Physicians who specialize in emergency medicine are disproportionately represented in the ranks of local and national health IT leaders. Examples include:
Dr. Brian Keaton, president of the American College of Emergency Physicians and an emergency medicine physician in Akron, Ohio, leads the Northeast Ohio Regional Health Information Organization (RHIO).
Dr. Edward Barthell, executive vice president of strategy and clinical affairs at Infinity HealthCare in Wisconsin and a practicing emergency medicine physician, is a founder of the Wisconsin Health Information Exchange (HIE).
Dr. John Halamka, an emergency medicine physician at Beth Israel Deaconess Medical Center in Boston, is chief information officer at Harvard Medical School and chairman of the Healthcare IT Standards Panel chartered by the federal government.
Dr. Craig Feied and Dr. Mark Smith, emergency medicine physicians at Washington Hospital Center, were among the creators of the Azyxxi software that Microsoft acquired for its foray into health IT.
In addition to such physicians’ prominence among health IT leaders, emergency departments are often the starting point for RHIOs and other projects that involve sharing all or part of patients’ records.
For example, the Wisconsin HIE’s first project, launched in June, involves linking the emergency departments of all Milwaukee County hospitals and safety-net clinics in the next two years. The goal is to improve coordination of care and increase patients’ safety by making their records available when they visit a hospital ER where they have not been treated recently.
Backers of the $5 million project include the Wisconsin Department of Health and Family Services, which is investing federal funds from a Medicaid Transformation Grant, and Microsoft, which will showcase the electronic medical records software it acquired in 2006.
Barthell’s experience as an emergency medicine physician and his knowledge of local hospitals’ ERs might have contributed to the Wisconsin HIE’s decision to start with the project. But he said the organization chose the ER environment mainly because sharing information in emergency situations is not as controversial as doing so for other types of medical care.
Many people are wary about having their health records exchanged electronically, Barthell said, but a good number of them believe that in an emergency, it is important for the doctors treating them to know their medical histories, and they might be unconscious or otherwise incapable of sharing that information with doctors.
The likelihood of measurable financial benefits for patients, hospitals, the state Medicaid program and other insurers also fueled the decision to start with an ER project, Barthell said. With medical records at their fingertips, ER doctors can avoid ordering duplicative tests and medications, and they will likely admit fewer patients for what could turn out to be unnecessary inpatient care.
States connect the ERs Wisconsin is not the only state to choose the ER environment for its initial HIE project. Once its network infrastructure is in place, the California RHIO, a public/private partnership, will link hospitals’ emergency departments and deliver laboratory test results as its first project, probably in mid-2008, said Karen Hunt, the organization’s director of communications.
And in Vermont, emergency departments in Rutland and St. Johnsbury are receiving patients’ medication histories. Vermont Information Technology Leaders, the state-sponsored organization behind the project, plans to evaluate the results before expanding the program.
Initial results are promising. More than 90 percent of patients have consented to sharing their medication histories, and 75 pe
rcent of the ER queries received results from a national clearinghouse called RxHub. Insurers and their pharmacy benefit managers supply the data to RxHub.
“Before, we asked patients for a list of all the drugs they are taking, or we had to look through bags of pills that patients brought with them,” said Irene Fortin, a nurse in the Rutland Regional Medical Center’s Emergency Department. “Many times, these lists were old or the bag had medication in it that was old, and we did much guessing. Now, with the electronic medication history, we have the drug names with the latest fill dates, which guides us, and all we have to do is verify with the patient that the information is correct.”
This also allows patients to be treated faster, she added. Regional projects In the Philadelphia area, Keystone Mercy Health Plan is delivering clinical summaries on Medicaid patients to ER doctors at six hospitals. The ER staff logs in to a Web site operated by MEDecision, a software, data and services company, to retrieve the information, which is derived from Keystone Mercy claims data.
Dr. Jay Feldstein, chief medical officer at Keystone Mercy, said he decided to deploy the system partly because he was impressed by an independent review of a similar system run by BlueCross BlueShield of Delaware and the Christiana Care Health System.
Researchers at HealthCore found that each time an ER physician at the Delaware hospitals pulled a patient clinical summary, medical costs were reduced by an average of $545. The savings came largely from expenditures related to laboratory evaluations, cardiac catheterizations, and medical and surgical supplies.
Moreover, the study showed a statistically significant increase in the rate of reimbursement to ER physicians.
“We believe that’s because the [patient clinical summary] makes the unknown known,” said Dr. Henry DePhillips III, chief medical officer at MEDecision. “So a physician who before would be treating a patient with a fractured femur is now treating a patient with a fractured femur who also has a history of renal failure and coronary disease. So that’s not upcoding in the negative sense. It’s more appropriate based on the level of medical complexity.”
However, relying on claims data to develop patient records has its drawbacks, Feldstein said. One challenge is the 60- to 90-day lag between when an ER visit occurs and when the medical charges are billed to the health plan and become part of the claims database. The health plan and MEDecision are addressing that issue.
ER physicians, though, are happy to have any information, DePhillips said. “They’ll tell you, ‘Maybe it’s not perfect, but it’s a whole lot better than what I had yesterday,’” he said.
Desperately seeking information The Northeast Ohio RHIO is linking the emergency departments at eight major hospitals in its region, which includes Cleveland, Akron and Canton. The organization is lining up funding and preparing to select an IT supplier for the project, Keaton said.
“We started this process because of the problem we have with ambulance diversions, with patients arriving at someplace other than their medical home and desperately needing information we couldn’t get,” he said.
In addition, ERs are where patients’ records are initiated or pulled from hospitals’ files. So it’s an ideal environment for beginning a master patient index that will link to files that might reside in several locations or information systems.
An emergency medicine doctor for 25 years, Keaton said he has long wanted to use IT to improve the care he provides.
“I’ve been constantly frustrated by things like having a patient discharged from the hospital across the bridge” after treatment for a heart attack, he said. “Now they’ve got chest pain, and they show up in my emergency department, and I have no more clue what happened to them than if they came from the other side of the moon.”
Keaton is also interested in reducing administrative bu
dens. “Hospitals spend a huge amount of money getting the results [of tests] from their laboratory to the physician who ordered the test,” he said. “Hospitals spend a huge amount of money checking eligibility for Medicare and Medicaid and private-pay patients. Yet all the data that’s necessary to do that is already flowing through the system. It’s just a matter of channeling it and bringing it together.”
Information systems can track patients and match them with available hospital beds, but Keaton and other emergency medicine physicians do not tout IT as the solution to the chronic overuse of the nation’s ERs. At best, it will help manage the flood, they say, but technology cannot stem the flow of patients who show up in ERs with complaints as mundane as a mild case of the flu or as life-threatening as a stroke or severe trauma.
Burgeoning business In a 2006 report, “The Future of Emergency Care in the U.S. Health System,” the Institute of Medicine wrote: “Not only has the hospital ED become the place that Americans turn to first when they have an illness or injury that demands immediate attention, but it has been given an increasing number of other responsibilities as well. EDs today provide much of the medical care for patients without medical insurance. Insured patients increasingly turn to the ED during times when their physician is unavailable, such as evenings and weekends, and they are often sent to the ED for tests and procedures that their physician can’t easily perform in the office. In some rural communities, the hospital ED may be the main source of health care for a large percentage of residents. EDs also play a key role in public health surveillance and in disaster preparation and response.”
“Emergency departments are highly motivated to put in clinical automation because of the challenge of overcrowding,” Halamka said. “It’s a need to be extraordinarily efficient. Without an automated tracking and clinical care system, it’s almost impossible to manage the logistics of a very overcrowded emergency department.”
But although ER doctors are receptive to technology, it hasn’t always served them well. When Dr. Todd Taylor worked as an ER doctor in Arizona in 2006, he used six clinical information systems and had to keep track of eight passwords that changed every 90 days. He is now a physician executive in Microsoft’s Health Solutions Group.
Such situations have prompted ER doctors to create a new generation of software that integrates clinical data and administrative information, such as patient location, bed availability and performance.
At Beth Israel Deaconess Medical Center, a group of doctors that included Halamka developed a dashboard system that gives doctors and other members of the ER staff a high-level view of what’s happening in the department and also allows them to see specifics for a patient or function, such as when more hospital beds will be available.
“Generally, we believe the only way the emergency department can be run is if you’re integrating every bit of data generated inside and outside the emergency department in one place where doctors can look at it without having to log in to 27 different systems, and that’s what the dashboard does,” Halamka said.
Some of the doctors have created a commercial version of the software that a company called Forerun markets to other emergency departments as an integrated information system.
Microsoft offers a comparable product called Azyxxi, developed by two emergency medicine doctors in Washington. Company officials describe the software as a platform for integrating almost any data that flows through a hospital. At the MedStar Health group of hospitals where Azyxxi originated, data from 1,500 sources — including radiology images and other unconventional kinds of information — flows into the system. Information can be viewed from any computer on the system in familiar formats such as spreadsheets. So far, 44 terabytes of data are available to MedStar’s doctors.
Taylor
aid Azyxxi is data-agnostic because the original format of the information doesn’t matter once it has been rolled into the database. Therefore, analysts can make connections between apples and oranges — or between ZIP codes and disease incidence, for example. Meanwhile, hospitals don’t have to abandon or convert their existing systems; they simply deliver copies of their data to Azyxxi.
Microsoft’s 2006 acquisition of Azyxxi was unusual because most of the company’s products are aimed at much wider swaths of the business, professional and personal computing markets. In fact, it is Microsoft’s first product for such a niche market.
The company is slowly releasing the software to the market, said Steve Shihadeh, general manager of sales, marketing and partners at Microsoft’s Health Solutions Group. The Johns Hopkins Hospital and Health System and New York-Presbyterian Hospital are the first customers, and both say they will use the product for all types of care, not just emergency medicine.
However, there’s good reason to think emergency medicine physicians will continue to be leaders in the use of health IT. As their workloads grow, they are under pressure to do more with less, and IT is one of the most promising ways to accomplish that feat.
From the battlefield to the home front: Managing medical data
Government Health IT presents Col. Claude Hines Jr., program manager for the Defense Health Information Management System, in this recent InSight eSeminar. Col. Hines discusses the health information technology and tactical challenges faced by the military medical community in Iraq, Afghanistan and other areas of conflict. In doing so, he describes the current information technology solutions for transferring clinical data between battlefield care givers to health care personnel at military treatment facilities worldwide.
