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 March 2012.A 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 (ICD-9) codes. Bivariate (χ2) and multivariate (logistic regression) analyses were performed to determine associations between predictor variables and the outcome of being an 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 an FEDU: age 35 to 44 years; African American race; Medicaid, Medicare, and dual-pay payer class; and ICD-9 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 tissueB 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.

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Health Information Exchanges (HIEs), multi-stakeholder organizations that enable the secure exchange and use of electronic health information, offer tremendous potential to improve health care quality, reduce medical errors, and lower costs by paving the way for increased interoperability and information-sharing among patients, providers, payors and other stakeholders. In fact, the state-based and regional HIEs already in operation are providing important user benefits such as more timely communication and secure patient data exchange, regional collaboration, and the elimination of inefficient and duplicate processes. In addition, HIEs are expected to play an important role as building blocks for a proposed National Health Information Network (NHIN) that promotes interconnectivity among users of various forms of health information technologies.HIEs are taking root across the country, despite technical, governance, institutional and funding challenges. Currently, there are more than 150 HIE projects in varying stages of maturity and employing several types of business models. Unfortunately, many of these HIEs may not exist long enough to realize their full potential because their business model is not financially sustainable. The key to sustainability is working with stakeholders to define and develop a business model that addresses the near term needs of individual stakeholders, yet is flexible enough to accommodate the diversity and evolution of these needs.There are many varieties of HIEs available today that are exchanging important health data ranging from comprehensive clinical information to e-prescribing transactions to lab data. Communities should select the type of HIE and business model(s) that best fulfills their stakeholders' needs and offers the greatest chance of early sustainability.The Deloitte Center for Health Solutions (the "Center"), a part of Deloitte & Touche USA LLP, has developed the following point-of-view document that explores the organizational and operational challenges facing today's HIEs as they seek to identify and implement a sustainable business model. The paper also shares characteristics of a successful HIE model and provides suggested strategies for long-term success.The spread of sustainable HIEs and other interoperable health information systems will enable the health care industry to take a major step forward in improving the quality, safety and efficiency of care. First, however, HIE stakeholders must embrace fiscal responsibility and viability to make sure that the promise of HIEs remains in lockstep with the economics.

IntroductionUse clinician perceptions to estimate the impact of a health information exchange (HIE) on emergency department (ED) care at four major hospital systems (HS) within a region. Use survey data provided by ED clinicians to estimate reduction in Medicare-allowable reimbursements (MARs) resulting from use of an HIE.MethodsWe conducted the study during a one-year period beginning in February 2012. Study sites included eleven EDs operated by four major HS in the region of a mid-sized Southeastern city, including one academic ED, five community hospital EDs, four free-standing EDs and 1 ED/Chest Pain Center (CPC) all of which participated in an HIE. The study design was observational, prospective using a voluntary, anonymous, online survey. Eligible participants included attending emergency physicians, residents, and mid-level providers (PA & NP). Survey items asked clinicians whether information obtained from the HIE changed resource use while caring for patients at the study sites and used branching logic to ascertain specific types of services avoided including laboratory/microbiology, radiology, consultations, and hospital admissions. Additional items asked how use of the HIE affected quality of care and length of stay. The survey was automated using a survey construction tool (REDCap Survey Software © 2010 Vanderbilt University). We calculated avoided MARs by multiplying the numbers and types of services reported to have been avoided. Average cost of an admission from the ED was based on direct cost trends for ED admissions within the region.ResultsDuring the 12-month study period we had 325,740 patient encounters and 7,525 logons to the HIE (utilization rate of 2.3%) by 231 ED clinicians practicing at the study sites. We collected 621 surveys representing 8.25% of logons of which 532 (85.7% of surveys) reported on patients who had information available in the HIE. Within this group the following services and MARs were reported to have been avoided [type of service: number of services; MARs]: Laboratory/Microbiology:187; $2,073, Radiology: 298; $475,840, Consultations: 61; $6,461, Hospital Admissions: 56; $551,282. Grand total of MARs avoided: $1,035,654; average $1,947 per patient who had information available in the HIE (Range: $1,491 – $2,395 between HS). Changes in management other than avoidance of a service were reported by 32.2% of participants. Participants stated that quality of care was improved for 89% of patients with information in the HIE. Eighty-two percent of participants reported that valuable time was saved with a mean time saved of 105 minutes.ConclusionObservational data provided by ED clinicians practicing at eleven EDs in a mid-sized Southeastern city showed an average reduction in MARs of $1,947 per patient who had information available in an HIE. The majority of reduced MARs were due to avoided radiology studies and hospital admissions. Over 80% of participants reported that quality of care was improved and valuable time was saved.

Objective: To quantify one aspect of emergency medicine (EM) Results: All 98 EMRPs meeting entry criteria responded to the survey. The medians for the percentage of times index procedures were performed in the E D by an EP were as follows (parentheses following percentages enclose 95% CIS): endotracheal intubation, 97% (95%, 100%); reduction of anterior shoulder dislocation, 93% (88%. 97%); thoracostomy, 63% (50%, 75%); transvenous pacer insertion, 60% (50%, 75%); cricothyrotomy, 50% (50%, 75%); thoracotomy, 50% (25%, 50%); diagnostic peritoneal lavage, 50% (25%, 50%); fiberoptic laryngoscopy, 22% (6%, 25%); sigmoidoscopy, 0% (O%, 6%); and pelvic sonography, 0% (O%, 0%).Conclusion: EPs in EDs of institutions that have EMRPs perform, on average, 50% of all index procedures (95% CI 47%, 52%). This information may assist EM programs experiencing difficulty in ensuring that their residents receive an equitable share of those procedures that are critical to their training.

Introduction:We determined if targeted education of emergency physicians (EPs) regarding the treatment of mental illness will improve their comfort level in treating psychiatric patients boarding in the emergency department (ED) awaiting admission.Methods:We performed a pilot study examining whether an educational intervention would change an EP’s comfort level in treating psychiatric boarder patients (PBPs). We identified a set of psychiatric emergencies that typically require admission or treatment beyond the scope of practice of emergency medicine. Diagnoses included major depression, schizophrenia, schizoaffective disorder, bipolar affective disorder, general anxiety disorder, suicidal ideation, and criminal behavior. We designed equivalent surveys to be used before and after an educational intervention. Each survey consisted of 10 scenarios of typical psychiatric patients. EPs were asked to rate their comfort levels in treating the described patients on a visual analogue scale. We calculated summary scores for the non intervention survey group (NINT) and intervention survey group (INT) and compared them using Student’s t-test.Results:Seventy-nine percent (33/42) of eligible participants completed the pre-intervention survey (21 attendings, 12 residents) and comprised the NINT group. Fifty-five percent (23/42) completed the post-intervention survey (16 attendings, 7 residents) comprising the INT group. A comparison of summary scores between ‘NINT’ and ‘INT’ groups showed a highly significant improvement in comfort levels with treating the patients described in the scenarios (P = 0.003). Improvements were noted on separate analysis for faculty (P = 0.039) and for residents (P = 0.012). Results of a sensitivity analysis excluding one highly significant scenario showed decreased, but still important differences between the NINT and INT groups for all participants and for residents, but not for faculty (all: P = 0.05; faculty: P = 0.25; residents: P = 0.03).Conclusion:This pilot study suggests that the comfort level of EPs, when asked to treat PBPs, may be improved with education. We believe our data support further study of this idea and of whether an improved comfort level will translate to a willingness to treat.

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