When a man is rushed into an ambulance with a possible heart attack, the paramedics must decide whether or not to administer clot-busting drugs to open a blocked coronary artery and if they should take him to the nearest hospital or to one that performs emergency cardiac procedures. Since lifesaving treatment should be administered within 90 minutes of a heart attack, these decisions are critical. A new software program helps paramedics make the right decisions, and a Web-based reporting system tracks their performance. This approach increased the proportion of heart attack patients receiving timely lifesaving treatment from 27 percent to 67 percent in one of the many pioneering health information technology (IT) projects funded by the Agency for Healthcare Research and Quality (AHRQ). These projects, which span technologies that range from decision support software and telemedicine to computerized drug and preventive-care alerts, are improving care and saving lives.
"That's not surprising, given that modern health care may be humanity's most information-dependent endeavor," says Jon White, M.D., director of AHRQ's health IT portfolio. The project to improve cardiac care for heart attack victims was led by Harry P. Selker, M.D., M.S.P.H., with Denise Daudelin, R.N., M.P.H., of Tufts Medical Center. It included two emergency medical service (EMS) agencies in two Massachusetts communities, who worked with researchers in conjunction with five community hospitals and three tertiary hospitals. The clinical decision support software system used electrocardiogram (ECG) results and patient information entered into the system by paramedics to determine the probability that the patient was having a heart attack and, if so, whether a cardiac procedure or clot-busting drugs were appropriate. The results were printed as text directly on top of the ECG to help paramedics determine the appropriate hospital, what treatment to start in the ambulance, and how to advise the emergency department (ED) staff on treatment needs while en route to the hospital.
A Web-based quality improvement reporting system, the TIPI-IS (Time-Insensitive Predictive Instrument Information System), integrated the data entered by the EMS agencies and hospitals to measure the quality of care provided to patients from the time they called 911 to receiving hospital treatment. The Web-based reports were used to educate paramedics on when to perform ECGs, how to interpret them, and when to direct a patient to a cardiac procedure-equipped hospital. The system also provided clinical outcomes on patients transported to the hospitals—information paramedics otherwise rarely get, helping them learn from their experience. This approach significantly improved paramedics' performance and confidence. It also convinced reluctant ED staff to trust paramedics' abilities to make sound decisions.
"One of the key objectives of this approach is to link together care in the community with care in the ED and hospital by having shared information on patients between the EMS, ED, and hospital," notes Dr. Selker. "The TIPI-IS approach provides the infrastructure and information along this continuum." The TIPI ECG text is available in conventional pre-hospital ECGs and the TIPI-IS reporting software is now commercially available and has been adopted by other EMS agencies to improve the care of heart attack victims. Like a number of AHRQ-supported projects in the health IT portfolio, once a project is over, the capacity/infrastructure to support sustained improvements in care remains.
Telemedicine in schools and child care centers
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In another AHRQ-funded health IT project, primary care physicians are using telemedicine to diagnose impoverished inner-city children who become ill while in school or a child care center. Their parents often risk losing income or jeopardizing their job when they take time off for sick-child visits. They are also more likely to bring their children to costly EDs instead of the physician's office for care. The Health-e-Access program has given children at 22 schools and child care sites access to telemedicine equipment and an on-site or roaming telehealth assistant, who can facilitate remote consultation with the child's own primary care physician in most cases. "It's both convenience and continuity—health care when and where you need it by people you know and trust. Who couldn't use more of that from health care?" comments project lead, Kenneth M. McConnochie, M.D., of the University of Rochester Medical Center.
The program recruited 10 physician practices in Rochester, New York, that already provided primary care to roughly 70 percent of children in the participating child sites. The remote consultations reduced absences from school and child care by more than half (since doctors can identify children who aren't a risk to other children and can still participate) and reduced ED visits (which cost seven times more than a telemedicine visit) by nearly 25 percent. Health-e-Access also improved access to care, with the children receiving 23 percent more care than a similar group of unenrolled children.
For the remote consultations, a trained telehealth assistant uses digital camera attachments to a computer to visualize a child's eyes, ears, nose, throat, and/or skin and an electronic stethoscope to record heart and lung sounds. This information is transmitted to the child's primary care doctor (or an "on call" telehealth doctor if the child's physician is not available). The doctor can also use a video camera to see and talk with the child to assess their condition. In most cases, a diagnosis is made and treatment prescribed, including a prescription that can be faxed to the local pharmacy. In only 4 percent of cases, the doctor suggested the need for an in-office visit, imaging studies, or laboratory tests. Also, 83 percent of physicians were as confident in the telemedicine diagnoses as those completed in person.
The researchers estimated that payers would save about $5.40 per child per year—close to $1 million for Rochester County's childhood population. "This analysis is sensitive to assumptions about rates of payment for telemedicine visits—rates not yet firmly established here," notes Dr. McConnochie. In response to a request from the Rochester City School district, telemedicine visits became available in all city schools as of September 2010. Health-e-Access also expanded in 2010 into elder care by introducing telemedicine access to locations such as assisted living environments and senior day care centers, whose clients often need wheelchair vans and medical attendants to accompany them to medical visits.
Electronic standing orders for health maintenance
Often access to care is not enough. Adults who visit the doctor for a sinus infection or other acute problems often walk out of the doctor's office not receiving important preventive or chronic-care screenings. For example, a patient with diabetes may visit the doctor for the flu, but may not be up to date with checks that can guide medical care, such as blood-glucose levels, lipid levels, or urinary microalbumin (that can indicate diabetes-related kidney problems). An elderly person may visit the doctor for back pain and leave the office without a flu or pneumonia vaccine. An AHRQ-funded health IT pilot project is tackling this problem head on. Electronic standing orders (SOs), highlighted in red on each patient's electronic health record (EHR) in the form of health maintenance alerts, authorize nurses and medical assistants to administer or schedule preventive tests or screenings when patients visit the doctor for any reason.
These SOs improved preventive care screenings by 6 to 10 percent, improved adult immunizations 8 to 17 percent, and improved diabetes care tasks up to 18 percent—all recommended care that may be overlooked during office visits for acute health issues. This is a significant problem. "A RAND study in 2003 showed that only 55 percent of adults received recommended preventive, chronic care, and acute care," says Lynn Nemeth, Ph.D., R.N., of the Medical University of South Carolina, project lead. She and colleagues examined the EHRs of patients at eight primary care practices that shared a common commercial EHR to identify what preventive services patients needed. A customized EHR health maintenance template outlined the schedule of testing, screening, and immunizations that should be provided to each patient based on the patient's disease(s), age, and gender.
Overdue items were highlighted in red in the health maintenance table, serving as electronic reminders. The reminders served as SOs for the nurse or medical assistant. During office visits these staffers updated the record with the patient (for example, they may have gotten a flu shot somewhere else between visits), administered needed vaccines (medical assistants are not allowed to do this in some States) and urinary or blood tests, and arranged orders for lab tests or other tests such as mammograms or bone density scans. The researchers implemented and evaluated electronic SOs for 15 measures in the areas of preventive screening (e.g., mammography, bone mineral density, cholesterol), adult immunizations (e.g., pneumonia, flu, tetanus, and zoster), and diabetes care (e.g., cholesterol, urinary microalbumin, and hemoglobin A1C—an indicator of blood-glucose control).
By updating patients' EHRs, administering vaccines or lab tests, and preparing referrals and paperwork for other tests, the nurses and medical assistants substantially improved patients' receipt of these services with minimal additional time. "As a result, physicians feel less burdened and clinical and office staff feel more engaged in patient care," comments Dr. Nemeth. Patients also benefit. For example, one participating doctor notes, "The project made us more aware that our patients were missing regular health maintenance... We did not realize that we missed this. We are now keeping up with their health maintenance issues and patients realize that they are cared about." GSM
Editor's note: To read about more health IT success stories and AHRQ's health IT research, go to http://www.healthit.ahrq.gov/HITFeaturedProjects. You can view the Health IT portfolio's Annual Report for 2009 at http://www.healthit.ahrq.gov/HIT2009Report.