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HIE’s Role in the Exchange of Poisoning Information

April 28, 2016
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In Utah, C-CDA messages to flow between poison centers, emergency departments

I have always been an advocate for making the investment in regional and statewide health information exchanges because I thought that use cases and benefits would continue to develop over time, making the HIEs invaluable to participants. A recent presentation during an AHRQ webinar described a great example. The Utah Health Information Network will be the hub for bidirectional data flow between emergency departments and poison control centers.

This story has a strong informatics element, but first the basic problem needs to be understood. Mollie Cummins, Ph.D., R.N., an associate professor in the College of Nursing at the University of Utah, described the scope of the challenge. She said there were 2.1 million poison exposures in the United States in 2014 alone, and 28 percent were managed in healthcare facilities. The number of fatalities has increased substantially in recent years, due to prescription drug abuse, she said, and in Utah, the death rate is among the highest in the nation.

Poison control centers are on the front line fielding calls. The specialists there are primarily nurses and pharmacists with education in toxicology. They assess the situation and make recommendations to the caller and/or provider about whether a caller should go to the emergency department (ED). They consult with the ED on poison exposure cases and make recommendations for treatment. They also play an important gatekeeping function because they keep the worried well out of the health system.

So how do poison control centers manage information? They use case-based poisoning information systems, which allows them to submit data to public health agencies for epidemiology and surveillance, but not readily share data with EHRs. So for sending information to the ED, Cummins said, they rely on phone and fax. The phone can be useful. It is low cost, with little to no configuration. But studies of healthcare environments have found there is a high risk for error in verbal communication.

On the ED side, phone calls are often interruptions that can lead to safety issues. Analyzing the information content of phone calls in detail has shown inefficiencies and safety vulnerabilities. Information is usually written on a paper form or Post-it note. And that information may or may not reach the clinician.

In calls between ED physicians and poison center pharmacists, there is no shared documentation to reference. Often, a poison center specialist has difficulty reaching the appropriate care provider and ends up exchanging information with a clerk.

Utah is in the middle of a 5-year project and research study that involves developing informatics tools to support a process with the HIE in the middle. They plan to evaluate the effect on workflow communications and usefulness.

“We want it to be standards-based and involve a process that can be replicable,” Cummins said. “We are not eliminating the phone. But we want to make data move and make it not just accessible but added to workflow at the point of decision making.”

The approach they are adopting is to have the poison center send Consolidated CDA (C-CDA) messages to the ED through the HIE. (They designed a C-CDA consultation note for the poisoning use case.) The ED will send back referral notes, progress notes, and discharge summaries. When the poison center sends the C-CDA, the information populates pre-arrival information in the ED tracking system. Clinicians there have one-click access to a full consultation note, with a summary of the case and an initial treatment recommendation. The ED can request a phone consultation with just a click. The process of sending notes back to the poison center is fully automated and invisible to care providers.

The Utah Poison Control Center is working with two Intermountain Healthcare community EDs on pre-implementation/post-implementation design, she said. They are looking at workflow and communication, efficiency, utilization and user evaluations of tools and processes.

One goal is to eventually share data in support of patient care across all EDs in Utah. And another goal is to move toward a learning health system for poisonings, Cummins said.  That would involve using data to learn how to better monitor, understand, prevent, and treat poison exposures, and use the same data for both clinical needs and public health.