C.M. Carr

Observational Study and Estimate of Cost Savings from Use of a Health Information Exchange in an Academic Emergency Department

BACKGROUND Federal initiatives to improve health care information sharing have led to the development of a new type of regional electronic medical record known as a health information exchange (HIE). OBJECTIVE Our aim was to investigate the ability of an HIE to decrease health services use for emergency department (ED) patients. METHODS We performed an observational, prospective study using a voluntary, anonymous survey among clinicians at an urban academic ED. All ED clinicians were eligible to participate. Survey items addressed clinician perception of whether information from the HIE avoided the use of hospital resources, improved quality of care, and reduced length of stay (LOS). Cost savings were estimated by multiplying the number of services the clinicians completing our survey reported they avoided through use of the HIE by the costs of those services at our facility. The study was approved by the Institutional Review Board at the study site. RESULTS The study was conducted between August and December of 2011. There were 18,529 patient encounters during the study period and 60 clinicians at the study site who were eligible to participate. The clinicians consulted the HIE for 5.39% of these encounters (998 patients). Surveys were completed by the clinicians caring for 13.8% (n = 138) of these patients. Of the completed surveys, 76% (105 surveys) referenced patients for whom the HIE was found to contain information on the patient under care by the clinician participant. These 105 patients formed the sample on which our analysis was based. Within this sample of patients, the following studies were reported to have been avoided by the clinicians participating in our survey: values are percent of patients for whom a study was reported to have been avoided (actual number of studies avoided): laboratory/microbiology: 30.5% (32 studies); radiologic studies: 47.6% (50 studies); consultations: 19% (20 consultations); and admissions: 11.4% (12 admissions). Calculated cost savings based on these estimates were as follows: laboratory/microbiology:

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

462.85; radiologic studies:

Prognostic value of CT-derived left atrial and left ventricular measures in patients with acute chest pain

160,893.00; consultations:

Computed Tomography-Derived Parameters of Myocardial Morphology and Function in Black and White Patients With Acute Chest Pain.

3,990.00; and admissions:

Health Information Exchange in the ED: What Do ED Clinicians Think?

118,131.84. Total savings:

When Should ED Physicians Use an HIE? Predicting Presence of Patient Data in an HIE.

283,477. Clinicians participating in the study reported improved quality of care for 86.7% of their patients, as well as a mean time savings of 120.8 minutes. CONCLUSIONS According to clinician estimates, use of an HIE in this urban academic ED resulted in reduced use of hospital resources, noteworthy cost savings, decreased LOS, and improved quality of care. Limitations included the observational nature of the study, selection bias, the Hawthorne effect, and cost estimates being from a single institution. Allowance was not made for additional services used because of information obtained from the HIE.

A Painful Ankle for Ten Weeks

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 (&khgr;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.

35 The Impact of a Health Information Exchange on the Management of Patients in an Urban Academic Emergency Department: An Observational Study and Cost Analysis

PURPOSE To determine which left atrial (LA) and left ventricular (LV) parameters are associated with future major adverse cardiac event (MACE) and whether these measurements have independent prognostic value beyond risk factors and computed tomography (CT)-derived coronary artery disease measures. MATERIALS AND METHODS This retrospective analysis was performed under an IRB waiver and in HIPAA compliance. Subjects underwent coronary CT angiography (CCTA) using a dual-source CT system for acute chest pain evaluation. LV mass, LV ejection fraction (EF), LV end-systolic volume (ESV) and LV end-diastolic volume (EDV), LA ESV and LA diameter, septal wall thickness and cardiac chamber diameters were measured. MACE was defined as cardiac death, non-fatal myocardial infarction, unstable angina, or late revascularization. The association between cardiac CT measures and the occurrence of MACE was quantified using Cox proportional hazard analysis. RESULTS 225 subjects (age, 56.2±11.2; 140 males) were analyzed, of whom 42 (18.7%) experienced a MACE during a median follow-up of 13 months. LA diameter (HR:1.07, 95%CI:1.01-1.13permm) and LV mass (HR:1.05, 95%CI:1.00-1.10perg) remained significant prognostic factor of MACE after controlling for Framingham risk score. LA diameter and LV mass were also found to have prognostic value independent of each other. The other morphologic and functional cardiac measures were no significant prognostic factors for MACE. CONCLUSION CT-derived LA diameter and LV mass are associated with future MACE in patients undergoing evaluation for chest pain, and portend independent prognostic value beyond traditional risk factors, coronary calcium score, and obstructive coronary artery disease.

The Impact of a Health Information Exchange on Resource Use and Medicare-Allowable Charges at Eleven Emergency Departments Operated by Four Major Hospital Systems in a Midsized Southeastern City: An Observational Study Using Clinician Estimates

Blacks have higher mortality and hospitalization rates because of congestive heart failure compared with white counterparts. Differences in cardiac structure and function may contribute to the racial disparity in cardiovascular outcomes. Our aim was to compare computed tomography (CT)-derived cardiac measurements between black patients with acute chest pain and age- and gender-matched white patients. We performed a retrospective analysis under an institutional review board waiver and in Health Insurance Portability and Accountability Act compliance. We investigated patients who underwent cardiac dual-source CT for acute chest pain. Myocardial mass, left ventricular (LV) ejection fraction, LV end-systolic volume, and LV end-diastolic volume were quantified using an automated analysis algorithm. Septal wall thickness and cardiac chamber diameters were manually measured. Measurements were compared by independent t test and linear regression. The study population consisted of 300 patients (150 black-mean age 54 ± 12 years; 46% men; 150 white-mean age 55 ± 11 years; 46% men). Myocardial mass was larger for blacks compared with white (176.1 ± 58.4 vs 155.9 ± 51.7 g, p = 0.002), which remained significant after adjusting for age, gender, body mass index, and hypertension. Septal wall thickness was slightly greater (11.9 ± 2.7 vs 11.2 ± 3.1 mm, p = 0.036). The LV inner diameter was moderately larger in black patients in systole (32.3 ± 9.0 vs 30.1 ± 5.4 ml, p = 0.010) and in diastole (50.1 ± 7.8 vs 48.9 ± 5.2 ml, p = 0.137), as well as LV end-diastolic volume (134.5 ± 42.7 vs 128.2 ± 30.6 ml, p = 0.143). Ejection fraction was nonsignificantly lower in blacks (67.1 ± 13.5% vs 69.0 ± 9.6%, p = 0.169). In conclusion, CT-derived myocardial mass was larger in blacks compared with whites, whereas LV functional parameters were generally not statistically different, suggesting that LV mass might be a possible contributing factor to the higher rate of cardiac events in blacks.

107 How Good are Paramedics and Emergency Physicians at Diagnosing a STEMI by EKG Compared to Cardiologists

Objectives Our regional health information exchange (HIE), known as Carolina eHealth Alliance (CeHA)-HIE, serves all major hospital systems in our region and is accessible to emergency department (ED) clinicians in those systems. We wanted to understand reasons for low CeHA-HIE utilization and explore options for improving it. Methods We implemented a 24-item user survey among ED clinician users of CeHA-HIE to investigate their perceptions of system usability and functionality, the quality of the information available through CeHA-HIE, the value of clinician time spent using CeHA-HIE, the ease of use of CeHA-HIE, and approaches for improving CeHA-HIE. Results Of the 231 ED clinicians surveyed, 51 responded, and among those, 48 reported having used CeHA-HIE and completed the survey. Conclusions Results show most ED clinicians believed that CeHA-HIE was easy to use and added value to their work, but they also desired better integration of information available from CeHA-HIE into their system’s electronic medical record.