Monday, June 22, 2015

Is Lack of Interoperability a Factor in Emergency Department Revisits and Readmissions?

In the revisit rates and associated costs after an emergency department encounter article, discusses the results and they are complex.  One interesting fact stand out.  The number of patients who seek further health-care from another ED is extremely high.  It is worth reading, but it is difficult to make sweeping judgments or generalizations.
People who return to the ED have multiple forces and motivations in play, including but not limited to:

1.      Convenience

2.      Impaired follow-up access.  For example, even though a patient may be instructed to recheck or follow-up with a primary care physician within a certain time frame, many cannot get a timely appointment without an established primary care network.  Many specialists will not see them without cash or health insurance, and those with coverage may have their access limited by policy requirements and unaffordable co-pays.

3.      Treatment failure.  Some patients do not get better.

4.      Dissatisfaction. Patients may feel their care was inadequate: questions were not addressed, testing was insufficient, or prescriptions given were inadequate or unaffordable.

5.      Narcotic Overlay.  If the patient was previously prescribe a narcotic(s) and/or wanted to receive a narcotic prescription that was not given, an added dimension for returning to (some) ED, is present.

6.      Mental Disturbance.  Many individuals have underlying psychological problems along with inadequate local community psychiatric/social support.  When a social worker is not available, some patients seek this kind of support from the ED, despite an actual need for individualized social services.

7.      The patient likes the ED or a particular ED doctor. 

These are extremely complex system level problems.  A potential solution may be to provide a social worker to help sort out the medical system, in addition to simply handing the patient discharge instructions.  Some institutions have established a system along these lines, called a medical advocate system.
Going to a different Emergency Department for a second or third visit seems to be a part of this phenomenon.  And there, in particular, is where the issue of interoperability arises.  Let’s assume that your EHR system is inherently good enough for internal interoperability, and that you have access to all the prior records- Right??  Now what about when the patient shows up across the river?  Would life not be simpler if each emergency department’s electronic health record had the interoperability capacity to talk to each other, to share data, and relate to the second ED what the first encountered and found?  This might lessen the need for repeating the entire work-up and admitting the patient.

Of course, from a practical standpoint, patients who are evidently sicker and return to the same or different emergency department usually get admitted to the hospital.  Repeat discharge happens, ut it does so with peril, as there are frequently solid medical, medical-legal, and logistic reasons, to keep the patient the second time.  Because beware willing to send home potential high risk bounce-back patients overall costs are inevitably driven up.
True interoperability, particularly by the establishment of industry-standard and required electronic documents, would greatly enhance patient safety by giving the next provider a better feel for what might have occurred at prior visits.

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