How should you use your clinical data under managed care?

EDs are lagging behind other specialties in applying data to performance measures

How important is data to your department’s viability under managed care? Health plans have been busy scouring providers for information that offers evidence of optimum performance in key areas. In recent years, hospitals and physician groups have been held up to intense scrutiny by health plans on key performance indicators such as daily census, lengths of patient stays, and patient satisfaction scores.

But emergency medicine has only recently begun to explore the link between health information management (HIM) and economic viability. The need for better information management systems in the specialty has been widely advocated by physicians, but slow to catch on.

Part of the reason is that at hospitals the data gleaned from emergency departments (EDs) have often been lumped together into a much larger sector of services that comprise all of a hospitals ambulatory care services. Emergency medicine isn’t ordinarily singled out as a separate form of ambulatory medicine, physicians say. Even industry-wide databases such as those kept by the American Hospital Association in Chicago, IL, don’t carve out emergency medicine as a separate ambulatory specialty.

Many researchers in the field believe that now is the time for EDs to study themselves and their clinical performance as a specialized segment of hospital-based medical care. And the best place to begin the effort, they argue, is in using data for clinical research, daily practice concerns, staff education, and administrative functions.

Emergency providers have lagged behind in information trend

"Emergency medicine, indeed, has a long way to go in reaching other clinical specialties in the way to use data to study itself as a specialty," says researcher Jonathan M. Teich, MD, PhD, an emergency physician at Brigham and Women’s Hospital in Boston, MA. "Essentially, we’re at the beginning of new age in emergency medicine."

In recent years, there has been a surge of interest in HIM as a specialized discipline. Medical informatics has become so important to physicians that seminars and conferences can’t do enough to satisfy the thirst for information on or about patient information.

Much of the attention has been content-based, focusing on coding and patient-chart documentation as part of the billing and payment function. But there’s been an equal amount of interest in context that includes computerizing a patient’s clinical data, securing the privacy of the data, and transmitting the information electronically using local area networks and the Internet.

Regulatory concerns involving fraud and abuse compliance have also spurred the growth of patient data and the internal auditing process.

But the effort has also moved into quality assurance and outcomes management. And researchers such as Teich see a compelling need for the specialty to make greater gains in exploiting information technologies.

"Emergency medicine, in particular, is an information-intensive specialty where immediate access to accurate information is critical in terms of patient care and cost-containment," says William H. Cordell, MD, an emergency physician in the emergency medicine and trauma center at Indiana University School of Medicine in Indianapolis.

But the information-gathering process is hampered by unavoidable circumstances. "Because emergency care is by its nature episodic, [physicians] as a rule don’t know individual patients," Cordell says. The situation inevitably forces physicians to practice a form of defensive medicine.

"They order extra tests, and because they never see the patient again, order them [the tests] all at once. Many of these tests may have been done before, but the results aren’t handy and so studies are repeated," Cordell says.

On a larger scale, some problems associated with drawing intelligent conclusions from patient data include the accuracy of taking data from only one hospital ED and making larger inferences from them. "Single EDs frequently lack sufficient patients or resources to collect and analyze data on many aspects of emergency medical care," Cordell states.

Need for formal standards in data use is paramount

Unlike other clinical specialties, these circumstances adversely skew data-based research results and negatively affect researchers’ ability to accurately gather data in an unpredictable emergency setting.

Teich and Cordell have developed a series of recommendations to help speed up the process of incorporating HIM in the performance evaluation process. They include:

• Hospitals and physician groups should establish formal standards for creating and sharing patient data within the medical infrastructure.

This means developing set standards for how the medical staff uses coded patient data, how the data gets transmitted internally and outside of the facility or office, and who is permitted to view the information and when. Patient privacy standards also play a vital role in these considerations, Cordell says.

• Differentiate the need for data for research and medical practice purposes.

According to Teich, the emphasis for clinical research should be on:

• collecting a wide variety of data types, including illnesses, patient age, and gender, etc.;

• enrolling as many patients or visit types into a formal study;

• maintaining regular and specialized inquiries using questionnaires and other sampling methods; and

• spotting trends in the data as they are being collected, capturing data across a variety of patient care sites.

The emphasis for clinical practice work should be on:

• keeping track of large numbers of patients simultaneously;

• quickly assimilating and organizing data from many different sources, such as x-ray, lab, and the ED itself;

• organizing and presenting the information to users and alerting them to important new data sets as they become available;

• keeping the information channels for information open and operating among patients, providers, and external sources such as referrals; and

• integrating the HIM system to meet both clinical and research needs.

The patient information has to be portable, says Cordell. It has to be interconnected with external audiences, including other integrated providers, local regulatory agencies, and relevant individuals such as payers and attorneys. But that doesn’t mean the data should be shared without confidentiality concerns.

Stand-alone, unconnected information systems are an anachronism, Cordell adds. Episodes of care rendered to the patient prior to the ED visit should be accessible and available to the attending physician to help guide decision-making and treatment.

Managing data should have full clinical staff support

• Integrate the ED and physician database with data from the rest of the hospital.

Doing so creates specific advantages for providers and patients, Teich says. They include the following:

• boosting the effectiveness of preventive care, including effects of vaccinations, screening tests, and access to primary care providers;

• helping in the physician or clinical department referral process;

• maximizing efficiency in patient arrivals at the ED and triage through data coordination;

• enabling physicians to determine the effectiveness of test, utilization patterns, and diagnostic algorithms typically used on certain patients;

• maximizing "door-to-treatment" times, the link between therapies and outcomes, and their relevance to certain patient demographics; and

• ensuring appropriate follow-up care from all sectors of the hospital, including lab and diagnostic clinics.

Managing data is key, says Cordell. "Information systems offer tremendous value to emergency medicine practice and research," he observes. But the effort has to be equally supported and nourished by the hospital and medical staff. Integration and uniform ethical and procedural standards are essential. "They can enhance the strength of the research effort and improve the practice by offering guidance based on solid evidence," Cordell concludes.