Hold Off on that Million-Dollar Workup: Here’s the Data You’re Looking For
Dan Seitz, MD (top)
Clinical Informatics Fellow
JT Finnell, MD, FACEP (bottom)
Associate Professor of Emergency Medicine, Indiana University School of Medicine
Director of Medical Informatics Fellowship, Regenstrief Institute, Inc.
Chief complaint: “Seeing red.” Hmm, I thought, perhaps this guy is being treated for tuberculosis and having some weird side effect from his medications? That rings a bell from med school. Within 10 seconds of walking into the room, though, I was hit with the sudden realization that something different was going on with this patient. A near-catatonic, disheveled young man sat rigid on the gurney in front of me as I asked some probing questions. “So, what brings you in today?” Silence. “What made you decide to come to the hospital today, sir?” Still a blank stare at the wall with no acknowledgement of the fly buzzing around the room, let alone the doctor sitting 3 feet away asking questions. Finally, after about round four of questioning, a single answer: “Seeing red.”
After a quick, unremarkable exam with limited participation from the patient aside from perseverating on his chief complaint, I politely excused myself from the room to head back to my workstation. I clicked on the chart and found about what I expected to find: absolutely nothing. No prior history, no med list, no previous workup. Wonderful. Veterinary medicine workup, it is. I clicked all the lab orders and a head CT, then paused before signing the orders. Maybe someone else had seen this guy and had some information.
Within seconds of loading up CareWeb, the access portal to the Indiana Health Information Exchange (IHIE), I hit the motherlode. An encounter from earlier that day at a facility outside our hospital network. Results populated on the screen as if I’d signed all those orders from a second ago and had them all immediately resulted. Head CT negative. BMP and CBC within normal limits. Ammonia and tox labs negative. Then, there it was, a note from the ED physician in which he had documented the phone number he’d gotten from a scrap of paper in the patient’s pocket, the one link to someone who’d be able to get some answers. Psychiatry contacted following a conversation with the patient’s sister, and a (second) million-dollar workup averted.
While my scenario that day was rather atypical, the feeling that if only I had access to the data related to this patient’s visit at another hospital is much more commonplace. Patients akin to the gentleman complaining of chest pain who “had the thing where they went up my groin to check my heart last month” but no documented evidence of such can be particularly frustrating. Most often the only choice in the absence of this data is to do more rather than less for the patient, an option that has not only financial implications but potential impacts on patient safety as well.
Fortunately, Indiana is home to one of the first and most robust state health information exchanges (HIEs). The Indiana Health Information Exchange (IHIE) was founded over a decade ago and has steadily built a robust information-sharing network that encompasses the vast majority of healthcare systems in Indiana. Currently they serve 117 hospitals across 38 different health systems and have data for 13.5 million patients. This data is accessible to any physician employed by an IHIE member, currently over 38,000 providers, or any provider at an affiliated HIE in a different state.
In the emergency department, CareWeb Search is akin to a Google search of a patient’s record, allowing physicians to pinpoint data elements that are of most value and to visualize trends in their history across multiple health systems and encounters. Statewide pharmacy data enables a more complete picture of a patient’s medication history, bringing to attention patients who are deemed high-risk for controlled substance abuse based on the contents of their past prescription history. As IHIE and other statewide HIEs continue to innovate in this space, new technologies like Fast Healthcare Interoperability Resources (FHIR) enable the EHR-agnostic blurring of the lines between a patient’s local and outside data. When these new technologies are combined with this treasure trove of standardized data, accessing, searching, and trending this data is not only possible but can be done in a flexible way that can be adapted to nearly any clinical workflow.
Beyond the state of Indiana, regional and national information sharing is well underway. The Strategic Health Information Exchange Collaborative (SHIEC) is a national consortium of state-run health information exchanges that encourages communication and collaboration across state lines. For Indiana, participation in SHIEC has yielded the creation of the Heartland Project, a cross-borders initiative connecting our state’s data with that of surrounding states. A patient check-in at any participating ED in the state triggers a query based on ZIP code to the patient’s home health information exchange, then pulls all available data for clinical review. The overarching objective of SHIEC is to build out a national exchange network while also equipping its members with best practices in the management, sharing, and use of this data.
If you’re the average emergency physician who currently lacks access to outside data, facilitating the next steps in your own institution’s engagement in such a large-scale effort may seem like a challenge. However, this may be as simple as reaching out to state-specific organizations dedicated to health information exchange participation and communicating physician interest and demand for this data. Connecting your own institution with others in your state and region via national networks like SHIEC (strategichie.com) has the potential to create benefits for all parties involved. The data not only flows from other hospitals to yours but the other way around as well, so both sides are incentivized to collaborate.
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