Supporting Continuity of Care for Poisonings With Electronic Information Exchange (Utah)

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Summary:

U.S. poison control centers (PCCs) are important resources for poison information, clinical toxicology consultation, and poison prevention education. While many use internal electronic records, PCCs and emergency departments (EDs) tend to exchange information over the telephone. Because of heavy communication loads and frequent interruptions in EDs, verbal communication is more prone to medical error. Reliance on communication by telephone thus creates safety vulnerabilities, delays in time to treatment, risk of data loss, and lack of adequate information at the point of decisionmaking. Moving toward electronic communication would help to reduce these risks.

This project identified the information requirements for health information exchange (HIE) between PCCs and EDs, described current information exchange scenarios, and identified the clinical, operational, and legal considerations important in creating such an exchange in support of patient care.

A variety of methods were used to conduct this research. Call recordings were analyzed to identify information requirements and process characteristics. Information types used in current PCC-ED communication were identified and mapped to standard clinical terminology systems, such as LOINC and SNOMED-CT. Mapping could not be done for approximately half of the information types, which indicates a need for further terminology development in this area. Interviews with providers were conducted to determine their current communication processes.  Finally, a Delphi study was conducted to determine clinical, operational, and legal considerations for a potential PCC-ED HIE.   

The project team concluded that the current telephone-based process of communication contains inefficiencies and potential safety vulnerabilities that could be ameliorated with an HIE. The building blocks for such an exchange process exist, but first a process that integrates well with the unique workflows of each of these settings must be determined.

Supporting Continuity of Care for Poisonings with Electronic Information Exchange - 2012

Summary Highlights

  • Principal Investigator: 
  • Organization: 
  • Funding Mechanism: 
    PAR: HS08-269: Exploratory and Developmental Grant to Improve Health Care Quality Through Health Information Technology (R21)
  • Grant Number: 
    R21 HS 018773
  • Project Period: 
    March 2010 – February 2013
  • AHRQ Funding Amount: 
    $299,078
  • PDF Version: 
    (PDF, 284.4 KB)

Summary: Exchange of information between poison control centers (PCCs) and emergency departments (EDs) is conducted almost entirely by telephone. In these high-volume and often chaotic settings, reliance on verbal communication increases the potential for data loss, delayed time to treatment, and medical error. The electronic exchange of information could improve continuity of care for poisonings, reduce time-to-treatment and medical errors, facilitate communication and availability of data to clinicians at the point of care, and ensure timely followup.

This project identified the data requirements for electronic information exchange between PCCs and EDs to support individual patient care and care transitions. The team described current information exchange scenarios as well as important clinical, operational, and legal considerations. The project team used multiple approaches, including interviews with clinicians and stakeholders, document review, analysis of recorded PCC calls, and a four-round Delphi study, to determine consensus among national experts on significant clinical, operational, and legal considerations.

Specific Aims:

  • Describe information requirements for electronic information exchange between PCCs and EDs. (Achieved)
  • Describe current data and information exchange scenarios between a regional PCC and an ED. (Achieved)
  • Identify salient clinical, operational, and legal considerations related to electronic exchange of data and information between PCCs and EDs. (Achieved)

2012 Activities: The research team completed the analyses for the first two aims based on multiple data sources: a review of documents, interviews with ED and PCC staff, and a detailed analysis of call recordings. Because all calls to and from PCCs are routinely recorded and archived, the team was able to analyze actual communication between EDs and PCCs with a non-intrusive approach. In 20-case increments, they analyzed information content in incremental batches using a saturation sampling approach. The research team completed analyzing the PCC to ED call recordings, including the analysis of inefficiencies and poor data quality. More than 120 unique data and information types were identified. In addition, the team completed interviews with ED providers (physicians and nurses) from Intermountain Medical Center and Primary Children’s Medical Center, as well as poison-control specialists to identify current data information exchange and user needs related to information exchange. Based on this work, the team developed process diagrams depicting the sequence of information exchange.

In the original grant proposal, Dr. Cummins had proposed to inventory the types of information exchanged, but during call analysis the research team also found many examples of inefficient data processes and poor data quality. The team decided to develop a taxonomy of the types of data process inefficiencies and poor data quality and went back and noted frequencies in order to more fully describe the data exchange process. The additional analysis provides valuable information about the nature and frequency of inefficiencies and poor data quality inherent in the current verbal information exchange process.

The results of the third aim were published in the July 2012 volume of Clinical Toxicology: Electronic information exchange between emergency departments and poison control centers: a Delphi study. Another manuscript – Inefficiencies and vulnerabilities of telephone based communication between U.S. poison control centers and emergency departments – is in press at Clinical Toxicology based on analysis of the call recordings conducted in 2012.

As last self-reported in the AHRQ Research Reporting System, project progress and activities are completely on track, and project budget spending is on target. Due to the added task of developing the taxonomy of the types of data processes and data quality, as well as the unanticipated amount of time it took to prepare the audio files for analysis, Dr. Cummins used a 1-year no-cost extension to complete the project.

Preliminary Impact and Findings: The process diagrams revealed that the current process is dependent upon verbal telephone communication between PCCs and EDs. ED-PCC collaboration occurs almost entirely between the physician and the poison control center, and multiple phone conversations support collaboration, monitoring, and followup of poisoned patients. There are many safety issues in terms of handoffs with different ED staff and playing “telephone” with information. Because it is difficult for the PCC staff to reach those caring for the patient on the phone, the information is given to an available person and is passed from person to person. As a result, encounter documentation and sharing of information across organizations is poor.

Target Population: General

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Knowledge Creation

Supporting Continuity of Care for Poisonings with Electronic Information Exchange - 2011

Summary Highlights

  • Principal Investigator: 
  • Organization: 
  • Funding Mechanism: 
    PAR: HS08-269: Exploratory and Developmental Grant to Improve Health Care Quality through Health Information Technology (R21)
  • Grant Number: 
    R21 HS 018773
  • Project Period: 
    March 2010 - February 2013
  • AHRQ Funding Amount: 
    $299,078
  • PDF Version: 
    (PDF, 182.06 KB)

Summary: Exchange of information between poison control centers (PCCs) and emergency departments (EDs) is conducted almost entirely by telephone. In these high-volume and often chaotic settings, however, reliance on verbal communication increases the potential for data loss, delayed time to treatment, and medical error. The electronic exchange of information could improve continuity of care for poisonings, reduce time-to-treatment and medical errors, facilitate communication and availability of data to clinicians at the point of care, and ensure timely followup.

This project identified the data requirements for electronic information exchange between PCCs and EDs to support individual patient care and care transitions. The team is describing current information exchange scenarios as well as important clinical, operational, and legal considerations. The project team is using multiple approaches, including interviews with clinicians and stakeholders, document review, analysis of recorded PCC calls, storyboarding, as well as a four-round Delphi study to determine consensus among national experts on significant clinical, operational, and legal considerations.

The results of this study will provide concrete guidance for efficient research and development on PCC-ED information exchange, including information technology solutions, standards adoption or development, and policy. Long-term implications include the study of outcomes, quality improvement innovations, and the potential for computerized decision support.

Specific Aims:

  • Describe information requirements for electronic information exchange between PCCs and EDs. (Ongoing)
  • Describe current data and information exchange scenarios between a regional PCC and an ED. (Ongoing)
  • Identify salient clinical, operational, and legal considerations related to electronic exchange of data and information between PCCs and EDs. (Achieved)

2011 Activities: The research team completed a four-round modified Delphi study to identify the clinical, operational, and legal considerations important for electronic information exchange between EDs and PCCs at the end of 2010. The team's focus in 2011 was on analysis, manuscript development, and dissemination of these considerations. Results of the modified Delphi study were presented at the Society for Academic Emergency Medicine's 2011 annual meeting in June, the North American Conference on Clinical Toxicology in September 2011, and the annual meeting of the American Medical Informatics Association in October 2011.

In addition, work continued on analyzing the PCC to ED call recordings. This included the time to identify, merge, clean, and transcribe the audio files before data analysis. Dr. Cummins and her team originally analyzed 60 calls and have sampled an additional 40 calls in 20-case increments. Analysis is ongoing. The project team will continue to sample in 20-case increments until they achieve saturation of information (e.g. no new types of data or information). Thus far, 120 unique data/information types have been identified.

In the original grant proposal, Dr. Cummins had proposed to inventory the types of information exchanged, but during call analysis the research team also found many examples of inefficient data processes and poor data quality. The team decided to develop a taxonomy of the types of data process inefficiencies and poor data quality and went back and noted frequencies in order to more fully describe the data exchange process. The additional analysis provides valuable information about the nature and frequency of inefficiencies and poor data quality, inherent in the current verbal information exchange process.

The team has begun interviews with ED providers (physicians and nurses) from Intermountain Medical Center and Primary Children's Medical Center, as well as poison-control specialists to identify current/ data information exchange and user needs related to information exchange. Twelve of an estimated 18-to- 24 interviews have been completed. The team has started to develop the process diagrams depicting the sequence of information exchange, and will finish the interviews by showing the diagrams to the interviewees to get validation of the process.

As last self-reported in the AHRQ Research Reporting System, project progress and activities are mostly on track and project budget spending is on target. Due to the added task of the taxonomy of the types of data processes and data quality, as well as the unanticipated amount of time it took to prepare the audio files for analysis, Dr. Cummins is using a 1-year no-cost extension to complete the call analysis and the storyboards to describe the exchange scenarios.

Preliminary Impact and Findings: The response rate for the modified Delphi study was high and stable. Upon completion of the fourth round, 115 of 122 statements had reached consensus. Panelists agreed upon the importance of most outcomes including effects on communication, information availability for decisionmaking, and medical error. They also agreed upon key aspects of adoption and implementation, and favor systems that support but do not replace verbal communication and consultation.

Target Population: General

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Knowledge Creation

Supporting Continuity of Care for Poisonings with Electronic Information Exchange - 2010

Summary Highlights

  • Principal Investigator: 
  • Organization: 
  • Funding Mechanism: 
    PAR: HS08-269: Exploratory and Developmental Grant to Improve Health Care Quality through Health Information Technology (R21)
  • Grant Number: 
    R21 HS 018773
  • Project Period: 
    March 2010 – November 2011
  • AHRQ Funding Amount: 
    $299,078
  • PDF Version: 
    (PDF, 372.92 KB)


Target Population: General

Summary: Exchange of information between poison control centers (PCCs) and emergency departments (EDs) is almost entirely conducted via telephone. In these high-volume and often chaotic settings, however, reliance on verbal communication increases the potential for data loss, delayed time to treatment, and medical error. The electronic exchange of information can improve continuity of care for poisonings, reduce time-to-treatment and medical errors, facilitate communication and availability of data to clinicians at the point of care, and ensure timely followup.

This project will describe the data requirements for electronic information exchange between PCCs and EDs to support individual patient care and care transitions. It will also describe current information exchange scenarios and identify important clinical, operational, and legal considerations. The project team will use multiple approaches, including interviews with clinicians and stakeholders, document review, analysis of recorded PCC calls, storyboarding, and domain-analysis modeling. In addition, a four-round Delphi study will determine consensus among national experts on significant clinical, operational, and legal considerations.

The results of this study will provide concrete guidance for efficient research and development on PCC-ED information exchange, including information technology solutions, standards adoption or development, and policy. Long-term implications include the study of outcomes, quality improvement innovations, and the potential for computerized decision support.

Specific Aims:
  • Describe information requirements for electronic information exchange between PCCs and EDs. (Ongoing)
  • Describe current data and information exchange scenarios between a regional PCC and an ED. (Upcoming)
  • Identify salient clinical, operational, and legal considerations related to electronic exchange of data and information between PCCs and EDs. (Ongoing)

2010 Activities: 2010 activities for this project focused on the preparation and recruitment of participants for the modified Delphi study to identify the clinical, operational, and legal considerations important for electronic information exchange between EDs and PCCs. Monthly team meetings addressed the content and conduct of Delphi study. The study team updated and expanded the literature search on electronic information exchange between PCCs and EDs. The literature was reviewed, synthesized, and illustrated with mind mapping software. The following thematic elements were identified: workflow integration, communication, medical error, data ownership, medico-legal issues, financing and sustainability, and adoption. Infrastructure development in support of the Delphi study was completed with the creation of recruitment materials, including letter and e-mail templates, documentation for survey rounds, and a timeline for materials distribution. Delphi participant recruitment was achieved using various methods, including in-person at conferences, word-of-mouth, and via informatics and emergency medicine listservs. By September 2010, the team exceeded their recruitment goal, identifying 71 committed Delphi study panelists, divided between PCC and ED as the primary domain of expertise. The Delphi study was conducted between September and December 2010. In round one, an initial subgroup (n=8) of experts responded to open-ended questions. Using thematic analysis, the study team converted responses to statements representing the spectrum of panelist opinion. Additional statements reflected literature-based concepts and analysis by the research team. In three subsequent rounds, the full panel reviewed statements describing potential outcomes of electronic information exchange, as well as issues affecting adoption and implementation. Results of the modified Delphi study were accepted for a presentation at the Society for Academic Emergency Medicine’s 2011 annual meeting.

In addition, work began analyzing the PCC to ED call recordings. The study team received University of Utah institutional review board approval for this study aim. The call-sampling plan was reviewed, and the team completed call sampling and initiated linkage to files. They will initially analyze 60 cases. If they do not achieve saturation of information (e.g. no new types of data or information), they will sample in 20-case increments until they achieve saturation.

Grantee's Most Recent Self-Reported Quarterly Status (as of December 2010): Project progress is completely on track, meeting all milestones on time. Project spending is somewhat underspent, approximately 5 to 20 percent.

Preliminary Impact and Findings: The response rate for the modified Delphi study was high and stable. The first round response rate was 0.73 (n=8), the second round response rate was 0.77 (n=55), the third round response rate was 0.75 (n=53), and fourth round response rate was 0.75 (n=53). Upon completion of the fourth round, most (115/122) statements had reached consensus. Seven statements failed to reach consensus. Panelists agreed upon importance of most outcomes including effects on communication, information availability for decisionmaking, and medical error. They also agreed upon key aspects of adoption and implementation, and favor systems that support, but do not replace verbal communication and consultation.

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Knowledge Creation

Supporting Continuity of Care for Poisonings With Electronic Information Exchange - Final Report

Citation:
Cummins MR, Crouch B, Gesteland P. Supporting Continuity of Care for Poisonings with Electronic Information Exchange - Final Report. (Prepared by University of Utah under Grant No. R21 HS018773). Rockville, MD: Agency for Healthcare Research and Quality, 2013. (PDF, 197.08 KB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
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