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Ch. 21 - EHRs and HIEs: Technology In Patient Care

Tom Fowler, MD; Patrick Olivieri, MD

Electronic medical records (EMRs) have been proliferating in emergency departments since the 1990s. This transition from paper to electronic was expedited in 2009, when the CMS implemented the “Meaningful Use” (MU) criteria. CMS offered incentives to
hospitals and providers that demonstrated use of EMRs, with the intention that EMRs would be used for more efficient collection of data that would give hospitals and government agencies the ability to produce accurate clinical reports. Increasing use of EMRs was also intended to assist providers with patient care tools such as medication warnings to decrease errors, improved information exchanges between hospitals to reduce duplicative workups.1

Government mandates on technology affect our day-to-day in emergency medicine.

Stage 1 of meaningful use focused on patient data such as demographics, vital signs, medications, and allergies. At first, hospitals were collecting data on all ED patients, which included information from patients treated and discharged from the ED and was found to be overly burdensome. Additionally, there was no certified computerized provider order entry (CPOE) requirement in the emergency department. CMS later incorporated modifications requiring data to be collected only on ED admitted patients, along with CPOE equirements in the ED.

Stage 2 involves advanced processes to exchange patient information between facilities (for example, by using Health Information Exchanges) and promote patient engagement (such as giving patients online access to medical records).2 The penalty for not meeting these goals was not only withheld CMS funds, but also an additional 3% reduction in Medicare/Medicaid reimbursements.

A provision was made for institutions to request exception to these penalties due to hardships, which CMS categorized as: limited Internet connectivity, uncontrollable circumstances, lack of certified EHR availability, and lack of faceto-face patient interactions.3

In 2015, the MU criteria were modified as part of the transition to the Merit-Based Incentive Payment System through the enactment of the Medicare Access and CHIP reauthorization Act so that “Meaningful Use Criteria” are now replaced by “Advancing Care Information.” Meaningful use was found to be overly rigid in its measures, with “all-or-nothing” incentives that were not aligned with other Medicare reporting programs and offered little flexibility for innovation. The AMA released a set of recommendations to HHS outlining an expressed need from the medical community for more flexibility with elimination of pass-fail program designs, allowing for multiple paths to end goals, removing threshold requirements for measures outside of a provider’s control, and allowing for data
reuse to decrease the burden of documentation.4

The goal of transitioning to Advancing Care Information is to make CMS objectives more customizable, more flexible based on the size and capabilities of institutions, and more synchronized with other Medicare reporting programs.5 These objectives will be met through a variety of quality measures, some of which will have a significant impact on the ED. Target goals for ePrescribing rates have been set for patients discharged from the emergency department to reduce errors and improve convenience. Patient access will increase by providing online portal capabilities that patients can login to for availability of test results and messaging with providers. There are requirements for patientspecific education materials included in discharge paperwork concerning the ED diagnosis. Additional measures include specifics on appropriate security risk analysis, patient-generated health data, exchange information with patients and other physicians, and clinical information reconciliation.6 Advancing Care Information streamlines measures and emphasizes interoperability, information exchange, and security measures. Clinical Decision Support and Computerized Provider Order Entry are no longer required, which will likely improve efficiency with documentation and reduce alert fatigue, but may have the unintended consequence of slowing the reduction in order entry related errors and protocoldriven improvements that CPOE and Clinical Decision Support may have supported.

Health Information Exchanges

With the growing ubiquity of EMRs in the United States, the next step may be to improve patient information exchange in between medical institutions using Health Information Exchanges (HIEs).

HIEs are varied throughout the country, with wide-ranging functionalities based on EHR vendors and interoperability infrastructures. While not commonly available yet, these exchanges offer an opportunity to dramatically change the medical information available for providers to provide better care to patients. By using HIEs, an emergency physician may have the ability to access all the patient’s records at all hospital facilities including labs values, EKGs, medication lists, imaging reports and discharge summaries.7 Having such broad access could dramatically reduce costs associated with unnecessary repeat imaging and laboratory studies and allow for comparison between current and previous EKGs, lab values and clinical situations, allowing for more informed and timely medical decision-making in the ED.

In one study, interviews were performed with providers working in an emergency department with reliable HIE capabilities to find what providers perceived to be the most beneficial aspect of having this tool available. Of the patient encounters where HIE was used during patient care, seeking specific information, 32% of HIE uses led to a change in clinical decision-making.8 Providers reported that HIE data contributed positively and significantly to patient care by providing lab result reference points and increasing provider
confidence in their medical decision making. HIEs have the potential to dramatically reduce information fragmentation when patients cross over between medical institutions that use different EHRs.9

Emergency Department Information Exchange

The Emergency Department information exchange (EDie) is an ACEP-backed way to make patient information accessible to emergency providers. Developed by Collective Medical Technologies©, EDie is intended to help coordinate care for patients. Whereas individual hospitals can be efficient for those who stay within that system, our patients don’t always stay within one system. In fact, up to a quarter of ED visits can be from patients who utilize multiple emergency departments.10

Nationally, there is an increasing focus on providing value-based care. One way to achieve this value is to reduce redundant testing. Relying on patients’ recollection of their prior visits and results can be risky. Repeating tests on patients transferred from another facility can cost hundreds of thousands of dollars to the average ED annually.11 Having the full picture on a patient’s pathology is incredibly valuable. With easy access to outside information, the belief is that this will allow us to appropriately and safely curb redundant testing.

It is early in the process, but EDie has already shown significant promise in Washington for helping improve care for emergency department patients. This program was initiated in Washington after concerns that overutilization of the ED was leading to rising costs. Washington State ACEP, Washington State Medical Association, and the Washington State Hospital Association worked together to implement EDie, integrating it into existing EHRs and streamlining the exchange of patient information. It is important to note that EDie was only one part of a “7 best practices” plan, which also includes identifying frequent fliers, implementing narcotic guidelines, and participating in prescription drug monitoring programs.12 After implementation, Washington saw improved outcomes in 80% of users subject to prescription drug misuse, as well as increased coordination through a primary care provider.13 In the first year alone, they were estimated to save $31 million as well as cut non-essential ED use by 10%.14

Government mandates on technology affect our day-to-day in emergency medicine. Even if not intended to apply to the ED, many of us work with EMRs that are part of a larger, integrated system than is subject to these mandates. EDie is a new, exciting form of HIE that is ACEP approved and gaining rapid support. So far, EDie is available in more than 550 hospitals with widespread use in Washington, Oregon, New Mexico, and Alaska. Because of its security and efficiency, expect to see it more widely available soon.

WHAT’S THE ASK?

  • Find out if your hospital EMR ready and able to work with EDie or another health information exchange.
  • Advocate with your state government for support for an HIE in your state to improve your practice.