A woman addicted to opioids walks into an emergency room, complaining of severe dental pain, leaves with a prescription for opioids and repeats the visit one week later, at another ER. A man complaining of chest pain is rushed to a hospital, gets a full battery of tests, is discharged and repeats the same round of tests in a different ER the following day. A woman who struggles with alcoholism is treated for the same head injury within 12 hours at emergency departments that are right across the street from each other.
"Cases like this happen all the time," says Dr. Scott Weiner, an emergency physician at Brigham and Women's Hospital and the president-elect of the Massachusetts College of Emergency Physicians (MACEP).
Now MACEP, in collaboration with the Massachusetts Hospital Association (MHA), has launched a pilot program that will alert hospitals across the state to patients who are in and out of emergency rooms on a regular basis.
"MHA strongly endorses the PreManage ED initiative as a solution for identifying and better coordinating care for high risk and complex patients, including patients with substance use disorder and mental health needs," said Anuj Goel, vice president for the association's legal and regulatory affairs. MHA is spending $2.6 million on the two-year pilot.
We asked Dr. Weiner to describe the project. Here's what he said:
What is the Premanage ED, sometimes called EDIE, and how does it work?
A patient checks in to an emergency room. Some basic information is entered into a secure central database including the patient's name, their primary care doctor, the hospital, the date and a summary of the diagnosis, such as chest or abdominal pain. If the patient has had six or more emergency room visits within six months, or three ER visits to three different hospitals in 90 days, or posed a recent security threat, the doctor treating the patient will receive a notice. We expect 10 to 20 percent of patients will trigger an alert.
What does that alert tell the doctor treating the patient? Can he or she see the tests they had recently or the medications they are on?
No, the information in the notice is very skeleton, just date, hospital, diagnosis. You have to call or request the test results electronically. But just the existence of that visit is essential information that we didn't have before.
How does the notice help?
In one recent case, maybe related to pain medication, the patient had abdominal pain, got a CAT scan of the belly and a bunch of lab tests, then IV opioids. The patient was discharged because doctors found no cause for the symptoms. The patient came over to my hospital. This case was just kind of lucky for me because I had the sensation that something didn't make sense. The patient presented at a late hour and had evidence of a recent blood draw. So I called the hospital close by and sure enough the patient had just been there. I was about to reinvent the wheel, order the CAT scan and the lab tests, a work-up that would have cost thousands of dollars and potentially harmed the patient.
In Washington state, where this program began, hospitals saved $30 million in the first year just from sharing information.
Do ER patients have to consent to have their records become part of this system?
No, there is a waiver of needing consent for emergency treatment. In an emergency situation, doctors can call another hospital and get recent test results. So it's deemed legal with emergency care to have an opt-out type system, where patients can say they don't want to be part of it — otherwise they are part of it. The data is exchanged in a secure fashion. There are other federal protections for patients diagnosed with substance use disorder, for example, notes on addiction treatment have to be hidden. But if a patient has overdosed, that would be transmitted, that's key information.
This project highlights some larger problems: patients who don't have a close relationship with a primary care doctor and the difficulty in sharing medical records. Do you see this as a band-aid for the moment?
I'd like to think so. Patients often assume that we have their information, that there's some sort of a network already. The state does have the Massachusetts Information Highway, where the goal was to make an exchange that would include all patients' records. That's an opt-in system that the state hasn't brought to fruition. We need to get to a point where there is one medical record. It doesn't make any sense that I don't have access to the test results from a hospital across the street. In 2018, that should just be a reality.
How many hospitals are participating?
The pilot started about six months ago. By the end of March, we expect 35 of the state's 67 acute care hospitals will be sending ER visits to the central database.