HIE Use in a Nevada Emergency Department
HealtHIE Nevada recently welcomed its first emergency department to the HIE. The participating physicians have already started integrating the exchange into their clinical workflow. Clinical access to information in the HIE begins with patient consent, so the hospital has built it into the registration process.
In the months ahead, HealtHIE Nevada will roll out access to other emergency departments around the state. Here, a Nevada emergency room physician shares how the HIE has helped him reduce unnecessary diagnostic tests, improving the accuracy, efficiency and cost of care.
I had a 30-year-old woman who had been discharged from a local hospital just hours previously.
She was admitted to the other hospital with shortness of breath three days prior. An X-ray at that time showed a mass in the chest, and a CT scan of the chest was performed. She did not know the results of these tests, but knew that a biopsy had been recommended and that the procedure was the reason she had been admitted to the hospital.
After the biopsy, she was discharged home with instructions to follow up with her primary care physician for results of the biopsy. The patient was still having active chest pain and shortness of breath, so she came to our ER for further care.
As a result of participating in HealtHIE Nevada, we had access to:
- CXR results and images
- CT scan results and images
- ER physician admit note from other hospital
- Cardiothoracic surgery consultation report
- Three physician progress notes
- Admission history and physical
- Discharge summary
Obviously, the additional diagnostic information was very instrumental in our ability to care for the patient. Without them, we probably would have attempted to obtain medical records from the other hospital, which is often a very time-consuming endeavor. After waiting for about three to four hours, we most likely would have just repeated the CT scan to ensure there were no major issues (and rule out complications from the biopsy).
Another benefit of the HIE that I didn't immediately realize was that I now had access to the names of the care team at the other facility. Without the HIE, if a clinical question were to come up, I would have to just cold-call the hospital operator and try to find out who saw a patient who was admitted four days prior. With the HIE, I had the name of the ER physician, the admitting attending of records, the CT surgeon who did the procedure and the radiologist who read the CT scan. In the future, it will be much easier to reach out and collaborate with other physicians because we will have their names. We ended up admitting the patient with no additional diagnostics other than an EKG and repeat chest X-ray. Through the use of the HIE, we definitely saved her some money and helped facilitate the admission.
I worked the rapid medical assessment shift on a recent evening and had at least two encounters where my initial approach was significantly changed because of the information the HIE was able to provide.
One was a patient who had been admitted to another hospital 10 days prior for abdominal pain. He presented during my shift saying that his abdominal pain was not any better and that nobody was doing anything for him. I grew suspicious and looked him up on the exchange. Sure enough, he had been admitted at that same hospital from 10 days ago in the interim and had been discharged after a two-day stay. He had also had an outpatient CT scan done at a radiology center in the four days since he had been discharged. I was able to pull up the discharge summary as well as the CT scan results from the radiology center and have all of that information available at the time of my triage assessment (within 30 minutes of his arrival). I easily would have ordered a CT scan had I not known any of that information. I was also able to confront the patient regarding his subsequent admission at the other hospital. Once I had all of the discharge documentation printed out and in front of him, he was suddenly able to recall the fact that he had been admitted to a hospital for two days. This, surprisingly, slipped his mind on our first encounter. We discussed some "ground rules" for good physician-patient communication, honesty of which was a key factor.
Another patient from my shift was a gentleman who said he was visiting from Egypt and had fallen out of his bed onto his lower back and sacral area. He was in the ER at my hospital four days prior, also for back pain, and also for falling out of his bed. I was able to pull up the records, which reflected the fact that imaging studies were recommended, but the patient declined to have them done. He left with a prescription for some pain medication and referral to spine surgery. He was now returning to the hospital stating that his back pain had worsened, and that "we were not doing enough to treat his pain." I was able to pull up his information on the exchange, and find that he had been seen at another hospital emergency department earlier that day. Funny, but he never mentioned that to us. Surprisingly enough, it appears that the mechanism of injury was that he had not just fallen out of his bed, but had fallen out of a bunk bed at the local jail where he had been incarcerated. This information was obtained from the emergency physician's documentation at the other hospital. Imaging studies had also been recommended at the other hospital, but the patient signed out against medical advice because he was not being administered pain medications. Again, the patient gave no history of an ED visit earlier in the day. This knowledge obviously added tremendously to our ability to discuss treatment options with the patient.
There are clearly occasions where patients will not tell the truth or willfully omit information. It is very empowering to have the HIE at our disposal, especially when the patients' complaints involve undifferentiated pain. These are the instances where imaging studies are frequently ordered by us in an attempt to rule out life-threatening or disabling causes of that pain. Having access to those imaging studies greatly reduces our utilization.