Making patient records available in the emergency department (ED) through a health information exchange (HIE) could boost adherence to guidelines and reduce unnecessary CT and MRI exams among patients who present to the ED with chronic headache, according to a study published online May 31 in the Journal of General Internal Medicine . However, the study reported HIE use did not reduce costs.
HIE offers the potential to curb unnecessary testing and improve quality of care; however, few studies have examined this hypothesis. James E. Bailey, MD, MPH, from the department of medicine at University of Tennessee Health Science Center in Memphis, and colleagues designed a longitudinal data analysis to determine the impact of HIE on three outcomes: diagnostic neuroimaging, evidence-based guideline adherence and estimated patient-visit costs.
Bailey et al referred to evidence-based guidelines which recommend advanced imaging only after thorough exam and only for a small subset of patients with high-risk headaches. Nevertheless, research suggests overuse, with a tendency among ED physicians to order duplicative or unnecessary CT, CT angiography, MR and MR angiography studies.
The researchers mined data from a regional HIE connecting 15 major hospitals and two regional clinic systems and focused on 2,101 repeat visits for 1,252 adult patients between Aug. 1, 2007, and July 31, 2009, with a primary discharge diagnosis of headache disorder. They determined any HIE use, HIE use by a physician or nurse practitioner and HIE use by administrative/nursing staff.
According to Bailey et al, the patients in the study averaged 2.7 visits for headache during the study period, and the HIE was accessed for 21.9 percent of the ED visits. HIE use was concentrated among administrative staff at 71 percent of access. Physicians and nurse practitioners accounted for 29 percent of HIE use.
The researchers surmised that the fairly low rate of HIE use is related to system factors and time constraints.
Physicians ordered neuroimaging in 69.8 percent of patient visits. Among visits that involved imaging patients, at least one CT of the head was ordered in 96.3 percent of cases.
“HIE use was associated with 62 percent lower odds of neuroimaging, and each additional previous visit was associated with 7 percent lower odds of neuroimaging,” wrote Bailey and colleagues. They also reported that HIE use was independently associated with improved adherence to guidelines and raised odds of adherence 33 percent. Each additional visit was linked with 7 percent higher odds of guidelines adherence.
The researchers estimated that HIE use resulted in the avoidance of 163 head CTs in a two-year period. “If HIE had been used in all cases, we estimate that as many as 748 CT scans could have been avoided,” they wrote.
However, HIE use did not reduce costs. The researchers estimated patient-visit costs at $249 adjusted cost/visit for non-HIE visits and $254 adjusted cost/visit for visits with HIE use. However, the findings may be related to confounding by indication, according to Bailey and colleagues, who wrote, “providers chose to access the HIE for patients posing greater diagnostic challenges.”
Bailey and colleagues stressed the significance of the results, noting HIE reduces potentially avoidable neuroimaging and improves adherence with guidelines. The findings represent an opportunity to improve quality and patient safety, while providing strong support for HIE adoption, they wrote.
Additional research focused on the effects of HIE on these outcomes is needed, according to the researchers. Bailey and colleagues have recorded similar results for imaging for back pain and also found a decrease in admissions for chest pain related to HIE use.