A Community-Shared Clinical Abstract to Improve Care

Care transitions are associated with information gaps, communication breakdowns, and lack of coordination that can lead to inefficiency, errors, safety risks, redundant effort, and patient dissatisfaction. Transitions to the hospital emergency department (ED) are especially problematic due to the urgency of the presenting problems and the limited objective clinical information available.

Three Twin Cities-based health care systems attempted to enhance continuity of care from the community to the ED by using a health information exchange (HIE) model. Under this model, the goal was to make prior clinical information from electronic medical record (EMR) systems accessible to ED clinicians and to evaluate the impact of that sharing. A number of barriers related to privacy and security were encountered that made it impossible to implement the proposed HIE during the study period. As a result, an alternative model was adopted.

An observational study of patients with congestive heart failure presenting to an ED in each health system was conducted to assess the effect of prior information on care quality and efficiency measures. Since the HIE model was not implemented during the study period, an alternative model was developed in which patients presenting to the ED who had accessible prior electronic clinical records in that health system's EMR were compared to patients who had no accessible prior clinical information. The authors hypothesized that the existence of prior information would be associated with better quality and efficiency of care.

Data were collected from the billing and clinical records of each health care system. Patients were classified as Internal if prior electronic clinical information was available or External if the information was not available. After adjusting for age, gender, race, marital status, and comorbidity, Internality had no effect on either ED length of stay or hospital length of stay. At the site with the greatest number of patients, Internal patients had lower odds of being hospitalized and, if hospitalized, lower odds of death in the hospital than External patients. The latter was also true at a second site. Internal patients at the most active site also had 6.4 percent fewer laboratory tests ordered than External patients. At a second site, the odds of having zero lab tests were similar for Internal and External patients but among patients with at least one laboratory test order, Internal patients had 14.9 percent fewer lab tests than External patients. Internal patients had significantly fewer medications ordered during the ED visit than External patients at each of the three ED sites with differences ranging from 26 percent to 35 percent Once barriers to HIE are overcome, there is evidence that HIE could be a valuable adjunct in the care of patients presenting to the ED.