Mark E. Frisse

The financial impact of health information exchange on emergency department care

Objective To examine the financial impact health information exchange (HIE) in emergency departments (EDs). Materials and Methods We studied all ED encounters over a 13-month period in which HIE data were accessed in all major emergency departments Memphis, Tennessee. HIE access encounter records were matched with similar encounter records without HIE access. Outcomes studied were ED-originated hospital admissions, admissions for observation, laboratory testing, head CT, body CT, ankle radiographs, chest radiographs, and echocardiograms. Our estimates employed generalized estimating equations for logistic regression models adjusted for admission type, length of stay, and Charlson co-morbidity index. Marginal probabilities were used to calculate changes in outcome variables and their financial consequences. Results HIE data were accessed in approximately 6.8% of ED visits across 12 EDs studied. In 11 EDs directly accessing HIE data only through a secure Web browser, access was associated with a decrease in hospital admissions (adjusted odds ratio (OR)=0.27; p<0001). In a 12th ED relying more on print summaries, HIE access was associated with a decrease in hospital admissions (OR=0.48; p<0001) and statistically significant decreases in head CT use, body CT use, and laboratory test ordering. Discussion Applied only to the study population, HIE access was associated with an annual cost savings of

Information retrieval from hypertext: update on the dynamic medical handbook project

1.9 million. Net of annual operating costs, HIE access reduced overall costs by

Estimated financial savings associated with health information exchange and ambulatory care referral

1.07 million. Hospital admission reductions accounted for 97.6% of total cost reductions. Conclusion Access to additional clinical data through HIE in emergency department settings is associated with net societal saving.

Health information exchange usage in emergency departments and clinics: the who, what, and why

This paper attempts to provide a perspective from which to develop a more complete theory of information retrieval from hypertext documents. Viewing hypertexts as large information spaces, we compare two general classes of navigation methods, classes we call local and global. We argue that global methods necessitate some form of “index space” conceptually separate from the hypertext “document space”. We note that the architectures of both spaces effect the ease with which one can apply various information retrieval algorithms. We identify a number of different index space and document space architectures and we discuss some of the associated trade-offs between hypertext functionality and computational complexity. We show how some index space architectures can be exploited for enhanced information retrieval, query refinement, and automated reasoning. Through analysis of a number of prototype systems, we discuss current limitations and future potentials for various hypertext information retrieval structures.

Health Information Exchange Reduces Repeated Diagnostic Imaging for Back Pain

Data and financial models based on an operational health information exchange suggest that health care delivery costs can be reduced by making clinical data available at the time of care in urban emergency departments. Reductions are the result of decreases in laboratory and radiographic tests, fewer admissions for observation, and lower overall emergency department costs. The likelihood of reducing these costs depends on the extent to which clinicians alter their workflow and take into account information available through the exchange from other institutions prior to initiating a treatment plan. Far greater savings can be realized in theory by identifying individuals presenting to emergency departments whose acute and long-term care needs are more suitably addressed at lower costs in ambulatory settings or medical homes. These alternative ambulatory settings can more effectively address the chronic care needs of those who receive most of their care in emergency departments. To support a shift from emergency room care to clinic care, health care information available through the health information exchange must be made available in both emergency department and ambulatory care settings. If practice workflow and patient behavior can be changed, a more effective and efficient care delivery system will be made possible through the secure exchange of clinical information across regional settings. These projections support the case for the financial viability of regional health information exchanges and motivate participation of hospitals and ambulatory care organizations-particularly in urban settings.

Searching for information in a hypertext medical handbook

OBJECTIVE Health information exchange (HIE) systems are being developed across the nation. Understanding approaches taken by existing successful exchanges can help new exchange efforts determine goals and plan implementations. The goal of this study was to explore characteristics of use and users of a successful regional HIE. DESIGN We used a mixed-method analysis, consisting of cross-sectional audit log data, semi-structured interviews, and direct observation in a sample of emergency departments and ambulatory safety net clinics actively using HIE. For each site, we measured overall usage trends, user logon statistics, and data types accessed by users. We also assessed reasons for use and outcomes of use. RESULTS Overall, users accessed HIE for 6.8% of all encounters, with higher rates of access for repeat visits, for patients with comorbidities, for patients known to have data in the exchange, and at sites providing HIE access to both nurses and physicians. Discharge summaries and test reports were the most frequently accessed data in the exchange. Providers consistently noted retrieving additional history, preventing repeat tests, comparing new results to retrieved results, and avoiding hospitalizations as a consequence of HIE access. CONCLUSION HIE use in emergency departments and ambulatory clinics was focused on patients where missing information was believed to be present in the exchange and was related to factors including the roles of people with access, the setting, and other site-specific issues that impacted the overall breadth of routine system use. These data should form an important foundation as other sites embark upon HIE implementation.

Paper: A tutorial introduction to stochastic simulation algorithms for belief networks

STUDY OBJECTIVE This study seeks to determine whether health information exchange reduces repeated diagnostic imaging and related costs in emergency back pain evaluation. METHODS This was a longitudinal data analysis of health information exchange patient-visit data. All repeated emergency department (ED) patient visits for back pain with previous ED diagnostic imaging to a Memphis metropolitan area ED between August 1, 2007, and July 31, 2009, were included. Use of a regional health information exchange by ED personnel to access the patients record during the emergency visit was the primary independent variable. Main outcomes included repeated lumbar or thoracic diagnostic imaging (radiograph, computed tomography [CT], or magnetic resonance imaging [MRI]) and total patient-visit estimated cost. RESULTS One hundred seventy-nine (22.4%) of the 800 qualifying repeated back pain visits resulted in repeated diagnostic imaging (radiograph 84.9%, CT 6.1%, and MRI 9.5%). Health information exchange use in the study population was low, at 12.5%, and health care providers as opposed to administrative/nursing staff accounted for 80% of the total health information exchange use. Health information exchange use by any ED personnel was associated with reduced repeated diagnostic imaging (odds ratio 0.36; 95% confidence interval 0.18 to 0.71), as was physician or nurse practitioner health information exchange use (odds ratio 0.47; 95% confidence interval 0.23 to 0.96). No cost savings were associated with health information exchange use because of increased CT imaging when health care providers used health information exchange. CONCLUSION Health information exchange use is associated with 64% lower odds of repeated diagnostic imaging in the emergency evaluation of back pain. Health information exchange effect on estimated costs was negligible. More studies are needed to evaluate specific strategies to increase health information exchange use and further decrease potentially unnecessary diagnostic imaging and associated costs of care.

Healthcare information technology and economics

Effective information retrieval from large medical hypertext systems will require a combination of browsing and full-text document retrieval techniques. Using a prototype hypertext medical therapeutics handbook, I discuss one approach to information retrieval problems in hypertext. This approach responds to a query by initially treating each hypertext card as a full-text document. It then utilizes information about document structure to propagate weights to neighboring cards and produces a ranked list of potential starting points for graphical browsing.

An Internet primer: resources and responsibilities.

Belief networks combine probabilistic knowledge with explicit information about conditional independence assumptions. A belief network consists of a directed acyclic graph in which the nodes represent variables and the edges express relationships of conditional dependence. When information about one variables state is given to the network in the form of evidence, an update algorithm computes the posterior marginal probability distributions for the remaining variables in the network. Many algorithms for performing this inference task have been proposed. Exact algorithms report precise results for some classes of networks, but take exponential time (in the number of nodes) both in the worst case and for many interesting networks. Stochastic simulation algorithms estimate the posterior marginal probability distribution for many graph topologies that would require exponential time when using an exact algorithm. Nonetheless, for some belief networks, stochastic simulation algorithms are also known to have exponential worst case performance. This article describes at a tutorial level several stochastic simulation algorithms for belief networks, and illustrates them on some simple examples. In addition, the theoretical and empirical performance of the algorithms is briefly surveyed.

Structure, navigation, and hypertext: the status of the navigation problem

At the 2011 American College of Medical Informatics (ACMI) Winter Symposium we studied the overlap between health IT and economics and what leading healthcare delivery organizations are achieving today using IT that might offer paths for the nation to follow for using health IT in healthcare reform. We recognized that health IT by itself can improve health value, but its main contribution to health value may be that it can make possible new care delivery models to achieve much larger value. Health IT is a critically important enabler to fundamental healthcare system changes that may be a way out of our current, severe problem of rising costs and national deficit. We review the current state of healthcare costs, federal health IT stimulus programs, and experiences of several leading organizations, and offer a model for how health IT fits into our health economic future.