Transcript Patient Engagement, Decision Support, and the EMR

Patient Engagement &
Decision Support in the
Emergency Department
Fahd Ahmad, MD, MSCI
Pediatric Emergency Medicine
Washington University in St. Louis &
St. Louis Children’s Hospital
The Problem
Healthcare providers are slowly being overwhelmed by data
Too many patients in given amount of time
Increasing volumes of medical research to apply
Long and/or complex medical histories
Fragmented patient records
The ED – all of the above, compounded by not enough data
Lack of patient familiarity, lack of time for in-depth discussions
Emergent condition the focus but rarely the only problem
Pediatrics – some too young to talk, parents not always reliable
historians
Patient Engagement
Having healthcare consumers more aware of and involved in
their own care
Health IT integral to better patient engagement
Most common use now are patient portals
Remote access for patients to see their test results
Download and review medical records
Asynchronous communication with healthcare providers
Patient Engagement
Patient engagement in the ED requires a different focus
Spend less time obtaining information, more time using it
Provide immediate details of acute illness
Concise summary of medical history
Screen for non-emergent but significant health/social issues
Real-time decision support within EMR (preferably w/NLP)
Improve the doctor-patient/parent relationship and decision
making
Overview
Adolescent health screening
Emergency Information forms
Highlight of other projects (in progress or planning)
Herpes Simplex Virus
Concussions
New initiatives
Sexually Transmitted Infections
Adolescents have highest burden of sexually transmitted infections
(STIs) in the United States
Chlamydia and gonorrhea two most commonly reported infections
in US
St. Louis among “leaders” inFigure
gonorrhea
and chlamydia
1. Comparison of Chlamydia Incidence Rates per 100,000
Cases per 100,000 people
Red=St. Louis
Blue=Missouri
Green=United States
City of St. Louis, Missouri, and United States. 2007-2011
STI Screening in the ED
Untreated infections with significant morbidities
Chronic abdominal pain
Ectopic pregnancy
Infertility
Improved screening and education methods needed
Adolescents frequently receive episodic care in the
emergency department (ED)
Often do not receive preventive/primary care
ED visits an opportunity to screen these youth for STIs
STI Screening in the ED
ED environment poses challenges to STI screening:
High patient volume
Primary complaint often not related to STIs
No pre-existing relationship
Lack of private space
Parent/guardian presence
Healthcare providers not familiar with screening guidelines
STI Screening in the ED
Audio-enhanced Computer-assisted self-interviews (ACASIs)
Self-directed electronic questionnaire
Completed in private
Audio component to aid comprehension
Prior studies demonstrate quality of ACASI collected data
Adolescents willing to disclose sensitive information via
ACASI
STI Screening – Pilot Study
Branch-logic questionnaire – sexual history via ACASI
Integrated decision tree created testing recommendation
Testing recommendation given to patient
Patient provides contact information via ACASI
Summary of information integrated into EMR
ED providers notified via EMR of available information
Testing ordered by doctor/nurse if at-risk of infection
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ACASI Pilot Results
Enrolled 800 patients
Median 8 minutes to complete
Almost all comfortable with system, prefer electronic format
Over 400 patients in need of STI testing, tested 50% of at-risk patients
Eighteen percent of those tested positive for chlamydia and/or
gonorrhea
Most positive tests in those without complaints related to STI
100% of patients notified of positive test, given treatment plans
Only one parental complaint
Figure 4. ACASI-eligible ED patients receiving STI testing regardless of ED complaint
Future Directions
Rebuild architecture for sustainable use (version 2.0)
Evaluate cost-effectiveness of method
Expand to include HIV, other sensitive issues, other
healthcare locations
PECARN – alcohol/drug abuse screening
Children’s Hospital of Philadelphia – depression screening
Cincinnati Children’s Hospital – suicide screening
Emergency Information Forms
Children with Special Health Care Needs (CSHCN)
Children who have, or at risk for chronic physical,
developmental, behavioral, or emotional condition who also
require health and related services of a type or amount
beyond that required by children generally.”
Increased risk for poor outcomes during medical emergencies
ED providers often do not have critical aspects of medical
histories available
CSHCN at-risk for significant complications
Emergency Information Forms
Emergency Information Forms (EIFs) provide essential
information in emergencies
Summary document for patient’s medical history
Major medical/surgical issues
What to do (or not to do) in case of specific emergencies
Contact information for subspecialists
Many barriers prevent widespread adoption
Paper easily torn/lost
Difficulty maintaining form
Has to be available at all times and in any setting
Commonly used for metabolic/genetic patients at SLCH
EIF Template from AAP
Google Health
Microsoft’s Health Vault
Clever countries….
Int J Biomed Comput. 1995 Oct;40(2):101-5.
Australian healthcare: a smart card for a
clever country.
Morris S1, Cooper J, Bomba D, Brankovic L, Miller M, Pacheco F.
Abstract
In this paper we give an overview of smart card technology how a smart card could be used as a healthcare card and the benefits that would most likely result
from doing so. The smart card memory can be zoned into different security levels. The top security zone may contain an individual's full medical history
while the lowest security zone may contain the cardholders name and address. Access to the different zones depends on the level of security of the zone. The
higher the security level the more restrictive the access method. Were smart cards adopted for the storage of medical histories it would change the form of
medical information recorded, not merely convert paper files to electronic ones. Storage of an individual's medical history on a smart card raises important
privacy issues. These privacy issues are discussed particularly as they relate to the Australian community.
PMID: 8847116 [PubMed - indexed for MEDLINE]
Clever countries….
Int J Biomed Comput. 1995 Oct;40(2):101-5.
Australian healthcare: a smart card for a
clever country.
Morris S1, Cooper J, Bomba D, Brankovic L, Miller M, Pacheco F.
Abstract
In this paper we give an overview of smart card technology how a smart card could be used as a healthcare card and the benefits that would most likely result
from doing so. The smart card memory can be zoned into different security levels. The top security zone may contain an individual's full medical history
while the lowest security zone may contain the cardholders name and address. Access to the different zones depends on the level of security of the zone. The
higher the security level the more restrictive the access method. Were smart cards adopted for the storage of medical histories it would change the form of
medical information recorded, not merely convert paper files to electronic ones. Storage of an individual's medical history on a smart card raises important
privacy issues. These privacy issues are discussed particularly as they relate to the Australian community.
PMID: 8847116 [PubMed - indexed for MEDLINE]
EIF in the US – What to do
next?
EIF Qualitative Study
Emergency Information Forms for Children with Special
Health Care Needs: A Qualitative Study
Copper TC, Jeffe DB, Ahmad F, Abraham G, Yu F, Hickey B,
Schnadower DS.
Objective: to identify facilitators and barriers to optimal
emergency care for CSHCN to inform the development of
EIFs for CSHCN.
EIF Qualitative Study
Twenty-six stakeholder interviews:
Emergency medicine providers
Community pediatricians
Subspecialty pediatricians
Paramedics
Parents of CSHCN
Health information technology specialists
Privacy compliance experts
To learn stakeholders’ preferred content, structure,
ownership, and maintenance of an EIF
EIF Qualitative Study
Barriers
Documentation 18/26 ( 11 providers, 4 IT, 3 PC)
Poor caregiver understanding 15/26 (10 providers, 1 parent, 3
IT, 1 PC)
Poor provider understanding 9/26 (3 providers, 4 parents, 2 IT)
Facilitators
Summary document 18/26 (12 providers, 4 parents, 2 IT)
Provider distrust of summary documents (2 parents)
EIF Qualitative Study
Content
Include: Demographics, primary facility, PMH, meds, allergies,
baseline exam, advanced directives, general disease info,
anticipated emergencies with action plan
Exclude: notes, old images/labs, social hx, vaccines, anything
irrelevant to chief complaint
Interface, Maintenance, and Access
Electronic 23/26 – 19 requested web-based with paper/USB
Should be created and updated by provider 19/26
Patient owned 13/26
EIFs
The ideal EIF:
Web-based with paper and/or USB copies available at all
times, particularly for pre-hospital or out of network
emergencies
Integrate into EMR and health information exchanges
Accessible anywhere, anytime, by appropriate healthcare
provider
“Owned” by patients, updated by physicians
Secure for patient confidentiality
EIF Simulation Study
Impact of Emergency Information Forms for Children
with Special Health Care Needs: A Simulation Study.
Abraham GG, Fehr JJ, Ahmad FA, Jeffe DB, White AJ, Yu F,
Copper TC, Schnadower D
Objective: To measure the impact and utility of EIFs in
simulated emergency scenarios of CSHCN.
EIF Simulation Study
Simulated ED scenarios of critically ill CSHCN
Compare provider and patient outcomes with and without an
EIF
Compare pediatric residents to pediatric emergency medicine
fellows and attendings
EIF Simulation Study
1
Estimates / obtains weight
1 point
Determines underlying disorder is
PA toxicity
Asks to keep patient NPO and stop
all G tube feeds.
Asks to access central line port
2 points
1 point
6*
Orders Electrolytes, VBG,
Accucheck, UA
Orders Ammonia
2 points
7*
Orders D10NS fluid bolus
2 points
8*
Orders IV fluids D10 NS at 1.5
times maintenance
Orders IV Carnitine at
100mg/kg/dose
Orders IV Ammonul (Sodium
Phenyacetate + Sodium Benzoate)
250 mg/kg/dose over 90 minutes
through the central line
Orders IV Meropenem 20mg/kg
2 points
Assessed using checklist 2*
of critical actions and 3
time to completion
4*
5
9*
10*
11*
Max total
1 point
1 point
2 points
3 points
2 points
16*/19
EIF Simulation Study
Provider performance with and without EIF
Scenarios with EIF
N=36
Scenarios without
EIF
N=36
P
Median critical action
score (IQR)
84.2% (71.7-94.1%)
12.5% (10.5-35.3%)
P<0.001
Median Time to
completion in min (IQR)
6.9 (5.8-10)
10 (constant)
P<0.001
Presence of complications
(95% CI)
30.6% (17.4-46.3%)
100% (92.2-100%)
p<0.001
EIF Simulation Study
Score by provider type
Senior physicians performed as poorly as residents without
an EIF
When EIF available, two groups performed equally well
Junior N=12
Senior N=12
P
With EIF (IQR)
87.5% (80.7-94.1%) 81.3% (70.0-94.3%) P=0.406
Without EIF
(IQR)
11.5% (6.2-22.9%)
20.4% (10.5-41%)
P=0.104
EIF Next Steps
Pilot demonstration project
Genetics/Metabolic clinic
PCF
Interface between a portable device and Health Record
Adaptable to Epic and other EHRs
Extraction software
Health Information Exchanges
Transition of care documents
Herpes Simplex Virus
Rare but serious viral infection
Causes significant morbidity and mortality in neonates
Significant uncertainty in which ill neonates require testing
Hospital guideline developed to provide guidance
EMR prompts when ordering HSV specific tests or meds
ED Testing decreased by 90% in low-risk patients
No missed HSV diagnoses
Concussions
A mild traumatic brain injury caused by biomechanical
forces
Regional and temporal cellular dysfunction that can include
cell death
Disturbance in brain function that is generally time-limited
Does not result in structural changes observable on CT or
MRI
Clinical diagnosis – no imaging or lab tests required
Concussion
Symptomatology
Most common symptom of pediatric concussion is headache
Symptoms are most severe in the first 3 days but improve and
resolve over 2 weeks
20-30% of children will have prolonged symptoms > 2 weeks
that effect their quality of life
250,000+ pediatric ED visits per year for concussion
Return to activity for most based based on symptom tracking
Adapted from:
M.R. Lovell, M.W. Collins, K. Podell,
J. Powell, J. Maroon
ImPACT: Immediate post-concussion
assessment and cognitive testing
NeuroHealth Systems, LLC,
New Initiatives
Abdominal pain
Gun violence/trauma
Apple ResearchKit