February 22, 2019

The Power of Precision: Pinpointing Frequent Visitors to the Emergency Department

emergency department, population health, electronic medical record, claims based data

Partners is leveraging data to understand why certain patients are turning to the emergency department rather than their primary care providers.

People often tout the potential power of data. At Partners Population Health, we rely heavily on data to evaluate, educate, and optimize our activities. But if you’re a clinician with a never-ending list of priorities, data reports can often seem like an overwhelming grab-bag rather than a set of useful tools. That’s why we’re turning to more focused data sets to help inform clinical strategy.

“We know that a subset of patients use the Emergency Department (ED) for non-urgent issues instead of going to their primary care physician. This can lead to fragmented care as well as higher health care costs. I thought, what if we could identify the most frequent utilizers of the Emergency Department and work to uncover why they are turning to the ED for care?” says Lara Terry, MD, Medical Director of Clinical Analytics and Informatics for Partners Population Health and a geriatrician at McLean Hospital.

People who use the Emergency Department (ED) multiple times a month are not only generating high costs, it can also be a signal they may not be receiving the care that they need through normal channels. Now with access to data from both claims and real-time clinical sources, the Partners Population Health team and members of the Partners Data and Analytics Organization are working together to identify individuals, their diagnosis, and the timing of when they went to the ED.

Not only does that level of detail help to pinpoint patients who are potentially in crisis, it helps to identify larger trends like diseases or diagnoses where there is unmet need, or systemic areas that could be addressed like after-hours access or triage for covering providers.

For example, this report helped validate what clinicians at Pentucket Medical Center were already seeing—that patients were using the emergency department for things like the flu when they could have gone to their primary care provider or an urgent care center. Even things like long wait times or crowded waiting rooms did not seem to deter patients.

“Patients like to have instant access which is, of course, the benefit of the emergency room,” says Jessica Hatch, DNP, CNL, RN, Population Health Clinical Manager at Pentucket Medical Center.  “But that’s not always the most appropriate place in these instances. We’re trying to get to the root of why so many patients don’t choose primary care or express care as an option and trying to educate them on the alternative.”

For the first time on a system-wide scale, Partners has been able to leverage both claims-based data and data from the electronic health record (EHR) to identify patients who are frequently going to the ED and/or are getting admitted to the hospital. These data allow clinicians to hotspot which patients could potentially benefit from a more timely intervention instead of waiting to be identified by our high-risk algorithm, potentially months later, or falling through the cracks completely.

The benefit of combining both claims-based data and data from the EHR is that it gives clinicians a clearer image of a patient’s true activity. Claims data gives a longitudinal view of every site a patient might have accessed while EHR data is beneficial because it can be seen in real time without the lag of claims processing. So, analysts can identify if a patient has had an event in a Partners facility in the last week, but they can also use claims data to see if that patient went to the ER while they were in Florida for the winter.

VIDEO: Perspectives on the ED Frequent Visitors List from Dr. Chaguturu & Stacey Moisuk, MPH, Manager for Program Analytics

Partners clinicians have started to use this tool to identify groups of patients, “phenotypes,” who crop up again and again on these frequent flyer lists. One that stands out are patients who have presented with a behavioral health diagnosis such as anxiety. Although this can be a diagnosed problem, some patients come to the emergency room repeatedly for issues like chest pain, palpitations, or shortness of breath without symptoms concerning enough to merit an inpatient admission. But, in the moment, these symptoms don’t necessarily get connected back to the original problem of anxiety.

“We are trying to understand in greater detail why certain patients use the emergency department so much,” says Jason Wasfy, MD, MPhil, Medical Director for Population Health Management at the Massachusetts General Physicians Organization. “With this information, we can develop creative clinical programs that meet the needs of these patients while also reducing preventable health care costs.”

Another group of frequent visitors that have been identified are usually elderly, frail patients that get admitted from the ED for an acute problem like a hip fracture. Dr. Terry explains that these initial problems lead to a domino effect of ailments that require more trips to the ED—urinary tract infections, pneumonia, or delirium—that are usually instigated by that first event.

“It becomes this kind of unfortunate cycle where one thing leads to another and they become more frail and their needs become more complex,” says Dr. Terry. “As a geriatrician those pain me. A lot of it can be avoided with a more proactive lens.”

By identifying these patients, clinicians are able to take tactical action and connect frequent ED visitors with programs like high-risk care management or additional behavioral health supports. The goal is by leveraging a suite of managed care services, including home-based care programs, we can address the needs of complex patients before they have a situation that requires a visit to the ED.


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