"Hidden" value: how indirect benefits of health information exchange further promote sustainability.

BACKGROUND: Health information exchanges (HIEs) have already demonstrated direct value in controlling the costs associated with utilization of emergency department services and with inpatient admissions from the emergency department. HIEs may also affect inpatient admissions originating from outside of the emergency department. OBJECTIVE: To assess if a potential association exists between a community-based HIE being used in hospital emergency departments and inpatient admissions emanating from outside of the emergency department. METHODS: The study design was observational, with an eligible population of fully insured plan members who sought emergency department care on at least 2 occasions over the study period between December 2008 and March 2010. Utilization data, obtained from medical and pharmacy claims, were matched to a list of emergency department utilizers where HIE querying could have occurred. Of the eligible members, 1482 underwent propensity score matching to create two 325-member groups-(1) a test group in which the HIE database was queried for all members in all of their emergency department visits, and (2) a control group in which the HIE database was not queried for any of the members in any emergency department visit. RESULTS: A post-propensity matching analysis showed that although the test group had more admissions per 1000 members overall (199 more admissions per 1000 members) than the control group, these admissions might have been more appropriate for inpatient treatment in general. The relative risk of an admission by the time of a first emergency department visit was 28% higher in the control group than the test group, although by the time of a second emergency department visit, it was only 8% lower in the control group. Moreover, test group admissions resulted in less time spent as inpatients, which was denoted by bed days per 1000 members (771 fewer bed days per 1000 members) and by average length of stay (4.27 days per admission for all admissions and 0.95 days per admission when catastrophic cases were removed). CONCLUSIONS: Based on these results, HIE availability in the care of patients presenting to the emergency department is associated with fewer inpatient hospital days and a shorter length of stay, even when catastrophic cases are removed from the analysis. Although many factors can play a role in this finding, it is possible that HIE promotion of more appropriate hospital admissions from outside of the emergency department is one cause. Such "indirect" value shows that the return on investment found by HIEs may even be greater than previously calculated. Additional study is warranted to further the business case for HIE investment for the various stakeholders who are interested in supporting HIE sustainability.

The business case for payer support of a community-based health information exchange: a humana pilot evaluating its effectiveness in cost control for plan members seeking emergency department care.

BACKGROUND: As emergency department utilization continues to increase, health plans must limit their cost exposure, which may be driven by duplicate testing and a lack of medical history at the point of care. Based on previous studies, health information exchanges (HIEs) can potentially provide health plans with the ability to address this need. OBJECTIVE: To assess the effectiveness of a community-based HIE in controlling plan costs arising from emergency department care for a health plan's members. Albert Tzeel. METHODS: The study design was observational, with an eligible population (N = 1482) of fully insured plan members who sought emergency department care on at least 2 occasions during the study period, from December 2008 through March 2010. Cost and utilization data, obtained from member claims, were matched to a list of persons utilizing the emergency department where HIE querying could have occurred. Eligible members underwent propensity score matching to create a test group (N = 326) in which the HIE database was queried in all emergency department visits, and a control group (N = 325) in which the HIE database was not queried in any emergency department visit. RESULTS: Post-propensity matching analysis showed that the test group achieved an average savings of $29 per emergency department visit compared with the control group. Decreased utilization of imaging procedures and diagnostic tests drove this cost-savings. CONCLUSIONS: When clinicians utilize HIE in the care of patients who present to the emergency department, the costs borne by a health plan providing coverage for these patients decrease. Although many factors can play a role in this finding, it is likely that HIEs obviate unnecessary service utilization through provision of historical medical information regarding specific patients at the point of care.

Syndromic surveillance using regional emergency medicine internet.

STUDY OBJECTIVE: We demonstrate the feasibility and utility of emergency department (ED) syndromic surveillance using a regional emergency medicine Internet application to minimize impact on ED and public health staffing. METHODS: Regional (multi-ED) surveillance was established for 2 periods, one characterized by a high-profile national sports event and the other during an international disease outbreak. Counts of patient visits meeting syndrome criteria and total patient visits were reported daily on the secure regional emergency medicine Internet site and downloaded by public health staff. Trends were analyzed and displayed on the secure Web site. ED participants were surveyed about the acceptability and time cost of the project. RESULTS: In the first ("All Star Game") project, 8 departments reported daily counts for 4 weeks, covering more than 26,000 patient visits. In the second ("severe acute respiratory syndrome" [SARS]) project, an average of 11 departments in the same region reported daily data on febrile respiratory illnesses, travel, and contacts for 10 weeks. Experience with the first project allowed for rapid implementation of the second project during a 3-day period. In both instances, the surveillance efforts were undertaken without the need for extraordinary ED or public health staffing requirements. CONCLUSION: A regional emergency medicine Internet approach permitted rapid implementation of multisite syndromic surveillance without additional staff. Some problems were identified with the first project, related to clinician checklist completion and manual data tabulation and entry. The SARS project addressed these by simplifying data collection and restricting it to triage.

The public health dashboard: a surveillance model for bioterrorism preparedness.

The City of Milwaukee Health Department piloted a short-term, near real-time syndromic surveillance and communication tool by using an existing secure regional Internet infrastructure. Voluntary, active syndromic case reporting by hospital Emergency Departments was combined with other data streams, including clinical laboratory reports of communicable disease, hospital emergency room diversions, ambulance runs, medical examiner reports of unusual or suspicious deaths, poison control and nursing hotline call volumes, and pharmacy over-the-counter sales. These data were aggregated into a "Surveillance Dashboard" format that was used to communicate community syndromic health trends to hospitals, Emergency Departments, and other providers using a secure Internet technology. Emergency Departments at 8 area hospitals reported a total of 314 cases meeting syndromic criteria from 26,888 patient encounters. Participants were satisfied with data entry and communications. All participating Emergency Departments received e-mail and text pager alerts sent by the Milwaukee Health Department. No unexplained findings or suggestions of an early outbreak were reported through syndrome surveillance for the 4-week duration of the project. Similar surveillance and communications systems could provide multiple benefits to Emergency Department workflow and management, as well as to public health and emergency response.

Assuring community emergency care capacity with collaborative Internet tools: the Milwaukee experience.

Hospital overcrowding and diversion of ambulances from emergency departments are being recognized as increasing problems in the health care system. This article, a descriptive narrative, examines the various factors contributing to the problem and describes how collaborative approaches to public health issues can be applied. It describes Milwaukee's experience with a collaborative approach. The use of a technological tool to assist with tracking and reporting on ambulance diversion and emergency department overload is explained, and data are provided to show the impact of various methods to blunt the impact of the flu season on diversion frequency. The article encourages use of similar collaborative approaches and Internet-based technology to address other public health problems.

The National Emergency Medical Extranet project.

The National Emergency Medical Extranet (NEME) project was a collaborative multi-center effort to create a plan for a networked system to improve emergency clinical care through real-time information support, and simultaneously provide benefit through information support for public health initiatives. This article presents a review of the NEME project and its recommendations, which are particularly relevant given the desire for improved communication and surveillance systems in today's healthcare and public health environments. Participants in the NEME project performed an environmental assessment and a proposed conceptual architecture for NEME. A consensus conference was held to review the NEME concept to obtain feedback and delineate priorities for future development and testing. The NEME consensus conference used a modified version of the nominal group method. Recommendations for the following areas were established: Business/Organizational Issues [1) create a compelling provider driven NEME model, 2) provide a comprehensive policy framework, 3) address economics]; Clinical/Caregiver Issues [1) develop a NEME system that is integrated with Emergency Medicine workflow, 2) provide incentives to caregivers, 3) generate a critical mass of participation for maximum benefit]; Technical Issues [1) incorporate a robust security and confidentiality architecture, 2) utilize a master person index, where appropriate, 3) evaluate or adopt existing data standards]; Heart Attack Alert Functional Priorities for NEME [1) continuous quality improvement and research, 2) regional electrocardiogram server, 3) past medical history and medication server]; Next Generation Internet Functional Priorities for NEME [1) real time epidemiology/surveillance, 2) patient education, 3) real time clinical alerting]. In conclusion, issues and consensus recommendations in the planning of a NEME are documented. These recommendations should be considered in future efforts to design, develop and implement wide area information networks to support Emergency Medicine. A review of current activities evolving from NEME is presented, and further research and development is encouraged to create and implement NEME systems.