The need for provider-notification and event-detection services for health information exchange (HIE) systems is quickly becoming a hot-button issue in the industry. During a recent discussion at the New York eHealth Collaborative’s digital health conference in New York, panelists talked about the importance of the service, which within an HIE notifies a primary care clinician, care manager or administrator when one of their patients has been admitted into the hospital. The two sides can correspond about vital patient information while the patient is in emergency care.
Thomas Check, senior vice president and CIO of the Visiting Nurse Services of New York (VNSNY) and one of the panelists, says the service is imperative for his organization. VNSNY, the largest not-for-profit home healthcare organization in the country, according to Check, has a patient population of 30 thousand people at any given time, which mostly includes older patients with multiple chronic conditions. These people, he says, have complex medical situations, request their care be done in the home, and they need that care over the long-term.
“They are the kind of folks that if there is an exacerbation that causes them to go into the emergency department, there’s going to be a significant challenge for an emergency physician who hasn’t seen them before to do the appropriate diagnoses and treatment,” Check said in an exclusive interview with Healthcare Informatics. “And they are the type of patients that are likely to become an inpatient, which is not the best thing for them medically and not the best thing for the health system economically, either.”
Check says once a VNSNY patient is in the ED, it’s vital that not only do the organization and the patient’s physician know, so they can adjust future care accordingly, but also the ED doctor needs to get information on the patient from the home care organization to understand the patient’s background while caring for them at that moment. This, he says, is the best way to avoid the patient being kept as an inpatient.
Through the various regional health information organizations (RHIOs) in VNSNY’s service area, the organization receives alerts about its patients being admitted to participating hospitals as soon as those admissions occur. Once the information is in hand, Check says the organization sends it to the EMR system so the nurses caring for that patient are aware they are in the ED. Also, if they have on-site staff at a particular hospital where the patient has been admitted, they can send the information to them.
For the most part, however, VNSNY has faced a communication barrier between itself and the ED physician. This barrier is the reason behind three provider-notification, event-detection pilots with New York City area hospitals, two of which are ongoing.
The first pilot wasn’t a success mainly due to workflow issues. In it, VNSNY would call the physician phone at the emergency room and notify them that their patient was in that emergency department and they could provide more information if need be. Despite an initial excitement from the hospital’s director of emergency medicine, Check says it was not possible to align the timing of the call and when the doctor needed the information.
“What they found was there’s a workflow in an emergency department,” Check says. “At the point the doctor sees the patient, that’s when they need the information. We would get the alert when the patient first registers in the emergency department and they wouldn’t be seeing a doctor until sometime later. At the time we would call, the doctor wasn’t ready to use the information. In fact, they didn’t know which resident was going to work with that patient. By the time the resident did interview with the patient, it was a distant memory that VNSNY had called.”
Pilots in Flight
To correct the issues from the first pilot, VNSNY underwent a second pilot whereby it faxes the vital information to the hospital so it can stay in the patient’s chart. Thus, when the doctor interviews the patient, the information is in the chart already. The central communications desk within the ED gets the fax (as well as a call from VNSNY) and then posts a notification on the ED’s electronic tracking board about the available information.
Thus far, Check says, the feedback on the second pilot has been good. He says VNSNY has been working with the hospital to let them know what kind of information might be in the fax. “Being in an ED is so busy, it’s really necessary to have the doctor learn whether the information is going to be valuable or not,” he says. “We’re confident the information is of value and physicians will incorporate it into their workflow.”
Another ongoing pilot, which has just started up, has VNSNY calling an answering service at the ED of the hospital and notifying the doctor what number they can call for more information about the patient. He said physicians at that hospital thought it would fit their workflow best. Since it has only been ongoing for a month, there has yet to be much feedback.
Check knows that the initial pilot programs couldn’t possibly solve all of the communication issues, but he says the organization will continue to learn from them and make changes. One possible easy fix could come with finding a way to implement a direct exchange between the homecare organization’s EMR and the ED physician’s EMR. He says the organization has worked with leading homecare EMR and physician EMR vendors on creating standards to do just that, a program that has been sponsored by the Office of the National Coordinator for Health Information Technology (ONC).
More than anything else, he says the most important aspect to getting this type of service off the ground is getting the right healthcare providers and organizations on board. He says especially the RHIOs, which connect all providers and share this information in the first place.
“Patients receive services from a lot of different healthcare providers, especially Medicare patients and patients with bigger health challenges,” Check says. “In a given RHIO, at least one-quarter of the patients have information that got there from more than one hospital. And most of these RHIOs are fairly young, so that number will go up. So the RHIO is really important as a way to bring that that information together for the different providers.”