Tuesday, November 15, 2011

What Does This Research Mean for the Proposed PCEHR? Sadly Not As Much As You Might Think!

The following paper was published last week. Here is the abstract and the introduction.
AMIA doi:10.1136/amiajnl-2011-000394

The financial impact of health information exchange on emergency department care

  1. Mark E Frisse1,2,
  2. Kevin B Johnson1,3,
  3. Hui Nian4,
  4. Coda L Davison1,
  5. Cynthia S Gadd1,
  6. Kim M Unertl1,
  7. Pat A Turri5,
  8. Qingxia Chen4
Correspondence to Dr Mark Frisse, Vanderbilt Center for Better Health, 3401 West End Avenue, Suite 290, Nashville, TN 37203, USA; mark.frisse@vanderbilt.edu
  • Received 24 May 2011
  • Accepted 5 October 2011
  • Published Online First 4 November 2011


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 $1.9 million. Net of annual operating costs, HIE access reduced overall costs by $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.
Care delivery is often distributed across multiple settings and is the joint responsibility of many providers who do not have access to the same electronic medical record.1–4 Access to a more comprehensive set of clinical data will be essential to improve care coordination as more care reimbursement shifts from fee-for-service to reimbursement plans exemplified by recent federal accountable care organization initiatives and Department of Health and Human Services meaningful use requirements.5–10 Access to all data required for medical decision-making makes good sense. Such access should reduce medical error, improve healthcare quality, and lower medical costs.11–13 Health information exchange (HIE) allows clinicians access to data originating from other sites of care or service. By our definition, HIE is a set of services that supports access among parties who are motivated by common interest and governed to ensure that the rights of patients and participants are protected. HIE can be achieved through services provided by one or more solitary health information organizations (HIO) and through direct, point-to-point communication among providers.14 15
The national experience with HIE is growing, both in terms of the number of sites exploring this technology16 17 and the business models that rely on it. Unfortunately, because of the economic immaturity of HIE, most HIE benefits are estimates.18–20 Reports of measurable financial benefit are few in number.21 22
Presenting convincing evidence is a challenge because of the relatively small but growing number of HIE efforts, the differences in HIE, the ways in which HIE is enabled and used, and the methodology challenge of measuring value in ‘real world’ settings. Although HIE among institutions usually takes place through a single intermediary HIO, as more organizations share data with one another on a point-to-point basis, measuring the marginal contribution of each external data source and thus the overall value of HIE will become even more problematical.23
As part of our 6-year effort providing access to clinical and administrative data through a single HIO supporting HIE for every consenting patient treated in any of the region's major hospitals and in some ambulatory care clinics, we conducted a 2-year study examining overall use, user perspectives, and a range of other factors.24–26 We report here the direct financial impact study results by determining how HIE data access by emergency department (ED) physicians affected hospital admissions and diagnostic testing.
Continue reading here for the full paper.
There is a press release on the study here:

Financial Impact of Sharing Electronic Health Information Focus of Study

Released: 11/7/2011 12:15 PM EST
Savings of nearly $2 million reported across Memphis EDs
Newswise — Sharing of electronic health information across every major emergency department in the Memphis, Tenn., area resulted in reduced hospital admissions, reduced radiology tests and an annual cost savings of nearly $2 million, according to a Vanderbilt study released today by the Journal of the American Medical Informatics Association.

“The Financial Impact of Health Information Exchange on Emergency Department Care,” led by Mark Frisse, M.D., MBA, professor of Biomedical Informatics, is the nation’s first city-wide study of the impact of widespread health information exchange (HIE) data access in emergency departments (EDs).

“This is the first study to show that, on a city-wide basis, investments in technology can save medical costs by improving care,” Frisse said.

“We took the ‘Tennessee simple’ approach and built a low-cost system that said, ‘Folks, if you do it simply and build it up, doing the right thing can save you money.’”

HIE represents the transformation from provider-centric collection of health care information to a more comprehensive, patient-focused view of this information, allowing electronic health records to be exchanged with other care providers and patient-authorized entities.

Patient privacy protection within the system is “as rigorous and secure as any commercial electronic health record system,” Frisse said.

“It makes available only the information you choose and it can only be used when you are needing care,” he said. “It is far more secure and useful than paper, even if it was all in one place. Health information exchange ensures that we know exactly who has looked at it, when, where and why. So it is accountable to you.”

Vanderbilt researchers studied all ED encounters in which HIE data were accessed in all 12 major emergency departments in Memphis, Tenn., over a 13-month period and matched those encounter records with a similar encounter record in which HIE data were not accessed.

Outcomes studied were ED-originated hospital admissions, admissions for observation, laboratory testing, head CT use, body CT use, ankle radiographs, chest radiographs and echocardiograms.

Clinicians used the technology voluntarily and only when they felt it was necessary for the patient -- about seven in every 100 cases. When HIE data was accessed, it was associated with a significant decrease in CT scans and hospitalizations.

“Our people believe that the savings from this study are less than 2 percent of the overall savings these technologies can afford if every physician’s office is connected,” Frisse said. “And we are absolutely convinced and committed to extending this approach to every health care setting.”

Frisse sees the study data as being a national model of how to take the first step.

“Emergency department care is such a very small part of our health care system, but the same value of complete information realized in emergency department settings is even more applicable when an elderly patient goes to multiple doctors without a single, comprehensive medical record,” Frisse said.

“It is the first step in showing that if you give physicians the tools to collaborate, they will voluntarily do the right thing for you, and they will save you money and your quality will improve. These are very busy emergency department physicians. They had to go look it up and they did it because they care.”
The release is found here:
The system used in this study was not, in fact, like the PCEHR. It shared Emergency Department encounter records and associated information from 12 substantial hospitals and made it possible to obtain information which was to be used by the attending clinicians - with the permission of the patient. The situation of the patient - being in a hospital emergency department - made it pretty likely consent would be able to be obtained. Interestingly the records seem to have been held a on a separate database from all the hospitals.
Information was only uploaded to the central data-base on an encounter basis and opt-out was very low at between 1% and 3%.
The number of times the system was used was between six and seven per cent of patient encounters.
The information was apparently not able to be added to by the patient nor accessed by the patient. Access was not available outside the hospital system for the trial. No plans for extension of the system into the community was mentioned as far as I can see.
Overall this report provides a very useful report on a model for Health Information Exchange which is fundamentally different from the PCEHR being provider centric, not user interactive and hospital based. The study is still worth a read! It does seem to be working, which is something I fear we will never say about the PCEHR as presently conceived!

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