Optimizing Alerts: The Cornerstone of HIE

Admit, discharge and transfer (ADT) alerts are proving their value as a key function in health information exchange across the country.

The human side of HIE-driven care coordination emerges in the story of a pregnant woman in a Minnesota-based maternal child health program who had scheduled a prenatal appointment with a nurse. Thanks to a transition of care alert, the public health agency involved learned that the woman had miscarried. Instead of preparing for a prenatal visit, the nurse gathered resources pertaining to grief. 

“The patient was very distraught, but the nurse worked with her on the grieving process. It was wonderful how the infrastructure of alerts, health information exchange and the continuity of care document worked seamlessly in this instance,” says Daniel Jensen, MPH, associate director of public health, Olmsted County Public Health Services—which is part of the Southeast Minnesota Beacon Community. “It’s sad to say but if the nurse had gone ahead without knowing about the miscarriage, she would have added to that person’s grief.” 

The Value of Alerts

Alerts are proving to be the cornerstone of HIE. By knowing when patients are admitted, discharged or seen in the emergency department, organizations can save time, provide better care coordination and ultimately cut costs and 30-day hospital readmissions. 

Maryland’s state HIE, the Chesapeake Regional Information System for our Patients (CRISP), implemented its Encounter Notification System in August 2012. The HIE connects all 46 hospitals in the state, as well as 900 providers and 48 organizations. 

Prior to full implementation, CRISP conducted a three-month pilot with five practices. It designed a system to send out alerts based on ADT data, utilizing Direct protocol. All pilot organizations uploaded a patient list to the HIE and received credentials with accounts. 

“The first thing we learned was that practices, even smaller ones, were reporting information overload,” says Ryan Bramble, CRISP’s director of integration. The goal, then, became helping the pilot group filter through the noise and act more meaningfully on the alerts. 

For larger practices experiencing a deluge of notifications, CRISP began delivering a spreadsheet at 6am each day that lists the previous day’s alerts. “The latest user group said it has made a huge difference,” says Bramble. 

The practices also requested more actionable data, including the chief complaint. The alerts provided demographic data but practices “quickly began asking for more information to determine if the alert is actionable.” CRISP thus enhanced the notification with hospital information and saw immediate improvement, says Bramble.

Information overload also became an issue when CurrentCare, Rhode Island’s HIE administered by the Rhode Island Quality Institute (RIQI), rolled out its notification system in June 2012. 

“When we initially rolled out, frankly it wasn’t successful,” says Jonathan Leviss, MD, RIQI’s chief medical officer. 

At that time, primary care providers were inundated with ADT alerts—many for less important transactions such as lab work registration. Primary care doctors don’t need to know that so “there was a lot of data that was making it difficult to see useful information.”

Ultimately, RIQI was able to limit alerts to emergency department and hospital encounters and moved the patient name and whether he or she was admitted to the hospital from the body of the message to the subject line of the email alert. Also, all alerts pertaining to the death of a patient contained that information in the subject line.  

The alerts were not seen as overload in a Southeast Minnesota Beacon Community pilot, which was launched with Olmstead County Public Health Services and the Mayo Clinic three months ago. Alerts move through its PHDoc electronic record system, which utilizes Nationwide Health Information Network protocols, including Direct, to care team members matched with a patient.

“We learned very early on that some nurses don’t like receiving text messages at 3 a.m.,” says Jensen, who said they restricted the hours of the alerts. 

The Beacon community in October began rolling out its program at its other collaborating institutions, which include 11 counties, public health offices and school districts. 

Workflow & Governance

Each provider, whether large or small, implemented alert systems differently into their workflow. CRISP Director of Outreach Cheryl B. Jones says the practices in the pilot adopted what works best for them, and often shared their experiences at user groups.

During implementation, RIQI regional extension center staff met with providers and care teams to address the workflow changes required to implement the alert tool, including implementing Direct and identifying the best person to handle the alerts and decide whether an alert warrants escalation of care. 

Since nurses and care team members often receive alerts, RIQI rebranded the alert system from “provider notification” to “hospital alerts,” he says. 

Full Speed Ahead

It’s too early to know whether the notifications will reduce hospital readmissions and costs, but the organizations say anecdotal evidence supports their use.  

Leviss reports a 10 percent reduction in 30-day readmissions within the past eight months but adds, “We are just beginning to explore what those numbers are. We’re not ready to say this is cause and effect; it’s an assessment.” 

In Minnesota, alerts take about 10 minutes compared to the three months it used to take to learn of a hospitalization. Once fully in place, the Beacon anticipates learning more about the alerts’ true impact.

CRISP is analyzing ADT alert data to produce reports on hospital readmissions. “We always thought the value is in the clinical data,” Bramble adds. “We’re really learning that ADT data provide tremendous value. It’s unexpected. It’s not the most difficult data to get, but it’s the most valuable.