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Electronic Collaboration: Using Technology to Solve Old Problems of Quality Care Kevin M. Baumlin, MD, Nicholas Genes, MD, Adam Landman, MD, Jason S. Shapiro, MD, Todd Taylor, MD, and Bruce Janiak, MD

Abstract The participants of the Electronic Collaboration working group of the 2010 Academic Emergency Medicine consensus conference developed recommendations and research questions for improving regional quality of care through the use of electronic collaboration. A writing group devised a working draft prior to the meeting and presented this to the breakout session at the consensus conference for input and approval. The recommendations include: 1) patient health information should be available electronically across the entire health care delivery system from the 9-1-1 call to the emergency department (ED) visit through hospitalization and outpatient care, 2) relevant patient health information should be shared electronically across the entire health care delivery system, 3) Web-based collaborative technologies should be employed to facilitate patient transfer and timely access to specialists, 4) personal health record adoption should be considered as a way to improve patient health, and 5) any comprehensive reform of regionalization in emergency care must include telemedicine. The workgroup emphasized the need for funding increases so that research in this new and exciting area can expand. ACADEMIC EMERGENCY MEDICINE 2010; 17:1312–1321 ª 2010 by the Society for Academic Emergency Medicine

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he world of information technology is rapidly changing, yet changes in health care have been slow.1–3 The science supporting how information technology will affect regionalization is sparse in many areas, although it is growing. The purpose of this article is to report on the efforts of the 2010 Academic Emergency Medicine consensus conference workgroup tasked with exploring the research agenda for how to improve regionalization through electronic collaboration. We decided to focus on the following broad topics: electronic health record (EHR) implementation,

From the Department of Emergency Medicine, Mount Sinai School of Medicine (KMB, NG, JSS), New York, NY; Brigham and Women’s Hospital of Harvard Medical School (AL), Boston, MA; Microsoft Corp. (TT), Seattle, WA; and the Medical College of Georgia (BJ), Augusta, GA. In 2006, Dr. Baumlin became President and CEO of Sunrise Solutions Group (SSG), Inc. During late 2007 and 2008, PICIS (an emergency department information system vendor) contracted with SSG to perform service related to assessing processes and performing application training for physicians and other staff members. PICIS in no way sponsored nor offered financial or other support for this work. Received July 20, 2010; revision received August 18, 2010; accepted August 25, 2010. Supervising Editor: Robert T. Gerhardt, MD, MPH. Address for correspondence and reprints: Kevin M. Baumlin, MD; e-mail: [email protected], jason.shapiro@mssm. edu.

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ISSN 1069-6563 PII ISSN 1069-6563583

regional health information exchange (HIE), Web-based collaborative tools, personal health records, and telemedicine. When considering EHRs, it is necessary to consider the nationwide status of emergency department (ED) EHR implementation. The 2003 survey by Pallin et al.4 and the recent work of Landman et al.5 suggest low levels of full implementation, although recent publications suggest both improved efficiencies and financial gain can be achieved with comprehensive implementation of fully integrated EHRs.6,7 The question now is not if EDs will implement fully functioning EHRs, but when. The next wave of implementation work will involve ED EHR integration of prehospital data and should help answer whether capturing and sharing prehospital data improves the overall care of patients. While EDs implement EHRs, will currently available technology be employed in other realms to enhance regional networks of care? We already know that regional stroke centers, trauma centers, and heart centers can improve outcomes.8–10 Perhaps simply sharing, comparing, and studying the protocols already in place that drive physician decision-making can affect care and quality across regions. The other use of information technology currently being studied is the data obtained and shared in regional health information organizations (RHIOs). Improvements in efficiency and cost savings may be early benefits, with decreased duplicate testing and potentially avoidable admissions—with further benefits to the

ª 2010 by the Society for Academic Emergency Medicine doi: 10.1111/j.1553-2712.2010.00933.x

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ED from that increased efficiency (i.e., decreased length of stay) and decreased invasive testing. Tests from transferring hospitals and other provider organizations would be readily available in a fully developed HIE implementation, obviating the need to repeat tests at the receiving facility. A functional HIE platform should bring about improved safety and quality at transitions of care, with the ability to view and reconcile medication lists, allergies, and more. Promoting direct patient involvement in electronic records has been espoused by mainstream vendors such as Microsoft, Google, Intel, and WebMD, with their personal health records (PHR) products, as well as by ED information system (EDIS) vendors with their own version of PHRs. While hospital-based EHRs have made electronic health data more prevalent, sharing these data outside hospital walls has been a challenge. Regulations like those resulting from the Health Insurance Portability and Accountability Act (HIPAA), security concerns, and the general fear of liability have created obstacles for sharing of protected health information. Realization of potential benefits,11 and legislation like the American Recovery and Reinvestment Act of 2009 (ARRA) requiring health data to be shared with patients, will ensure increased acceptance of PHRs in the future. Finally, electronic collaboration in regionalization means a more prominent role for telemedicine. Teleconsults have the potential to reduce admissions and length of stay, while expanding a specialist’s coverage area and improving patient satisfaction. The most appropriate form that telemedicine will take will likely depend on the patient—because of both the disease and the demographic. Incarcerated patients, nursing home and debilitated patients, rural patients, and school children are among the populations who could especially benefit from telemedicine. Already there are success stories and encouraging data, but significant challenges remain before robust telemedicine solutions can be employed in regionalized care networks. PREHOSPITAL AND EDIS ADOPTION AND INTEGRATION Recommendation 1 Patient health information should be available electronically across the entire health care delivery system, from the 9-1-1 call to ED visit through hospitalization and outpatient care. Background Electronic health records have the potential to improve health care delivery and have been shown to improve adherence to guidelines, reduce medication errors, and enhance surveillance and monitoring.12 Health information technology (HIT) may be particularly beneficial in the ED, a complex, data-intensive environment where providers typically care for new patients, many with complicated medical histories.13 As regionalization of care expands, increased coordination of care among primary care providers (PCPs), community hospitals, and regional referral centers will be required. Sharing complete EHRs among all providers may help

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deliver high-quality, efficient care in a regionalized environment. Having a full understanding of a patient’s medical history is essential. Local EDs often evaluate complicated patients without the benefit of outside medical records. When patients are transferred to referral centers, they are often sent with photocopies of local records. Sharing electronic health information in real time across the health care delivery system has the potential to decrease inappropriate patient transfers, ensure continuity of care, and enable sophisticated telemedicine consultation. Emergency medical services (EMS) providers are critical to the success of regionalized health care systems. In emergency settings, these providers often triage patients to the appropriate receiving facility, such as trauma, stroke, or cardiac centers. Prehospital providers also perform interfacility transports, moving patients from local hospitals to regional referral centers. Given prehospital care’s central role in emergency care, and regionalization in particular, electronic prehospital care reports must be fully integrated with the overall health care data system to improve communications, quality improvement activities, and outcomes research.14–17 The key to realizing the benefits of HIT for regionalized health care is to establish an infrastructure where complete patient information can be exchanged seamlessly among all providers.17 First, EDs, hospitals, outpatient offices, and prehospital providers must adopt electronic information systems. Next, these information systems must be able to securely exchange information. With funding from ARRA, the federal government is supporting the adoption of HIT and regional health information exchange centers, as well as a National Health Information Network architecture to enable secure, electronic exchange of health information.18,19 Current State In 2002, the National Hospital Ambulatory Medical Care Survey estimated that 31% of U.S. EDs had some kind of EDIS.19 However, two more recent studies found lower adoption rates when the features supported by the EDIS were considered.20,21 One study found that only 1.7% of EDs have fully functional systems, and 12.3% have basic systems.21 Furthermore, 54% of EDs reported no EDIS. These adoption rates are comparable to findings that 17% of office-based physicians have an EHR available, but only 4% have a fully functional EHR.22 Measuring HIT adoption is important to understanding our health care system’s current HIT capacity and future needs, as a possible future measure of quality and performance-related payments, and as a baseline to evaluate federal incentive programs.21,23 Challenges to measuring EDIS adoption include lack of a simple, standardized EDIS definition, survey respondent bias or lack of technical knowledge, and rapid changes in HIT capabilities. Suggested barriers to EDIS adoption and implementation include expense, difficulty of use, lack of staff acceptance, and fear of investing in equipment that becomes outdated rapidly.24 Prehospital care leaders have established the National EMS Information System (NEMSIS) project, which has standardized EMS data elements, created an

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XML-based transmission standard for EMS-related data, and created a national EMS data repository.15,16 A majority of states have a system in place to collect data from local EMS providers;25 however, only 14 states submitted data to the national EMS database in the first quarter of 2010 (from the Current Composition of the NEMSIS Data Warehouse, National Report updated July 4, 2010, accessed on August 16, 2010).26 While some states have mandated conversion to electronic patient care reports (e-PCR), no formal studies of e-PCR adoption at the EMS agency level have been performed. Furthermore, no studies have investigated the extent of e-PCR data integration with other electronic health data. Anecdotal data suggest that barriers to adoption of e-PCRs and contributing to the NEMSIS database are largely financial.25 The 2009 ARRA provides approximately $40 billion in funding to support the adoption and meaningful use of HIT.18 Hospitals and physician offices will be rewarded for meeting (or penalized in later years for failing to meet) specific information system capability goals and reporting clinical quality measures.26,27 Emergency physicians are not eligible to receive incentive payments directly; however, ED patient encounters now count toward the percentage-based measures hospitals are required to fulfill to achieve meaningful use.27,28 ED adoption of computer-based physician order entry; electronic problem, medication, and allergy lists; and electronic capture of demographics, vital signs, and smoking status will therefore help hospitals qualify for incentive payments.29 Furthermore, hospitals will be required to report ED-related clinical quality measures for payment year 2011–2012, including ED throughput measures and time to thrombolytic therapy in patients with acute ischemic stroke.28 No prehospital metrics are currently included in meaningful use criteria. As more emergency care quality metrics are developed and validated, additional ED-related meaningful use criteria are likely to be incorporated. It is unclear whether or not the current meaningful use criteria and incentive payment plans will be necessary or sufficient to increase the adoption of HIT, in general or EDIS and prehospital information systems, in particular. In addition to increasing adoption of information systems in the hospital, ED, and prehospital care settings, these information systems must be integrated within and across health systems to be beneficial for regionalization of emergency care.17 There are complex interoperability challenges that need to be overcome to ensure real-time information sharing. Indianapolis is one community that has had great success in exchanging information between hospitals, EDs, and now prehospital providers.30 The federal government is investing in regional health information exchanges and developing a Nationwide Health Information Network (NHIN) architecture to provide standards, services, and a secure architecture to exchange health information over the Internet. While these federal programs offer guidance and financial resources, the specifics of how ED and prehospital data will be exchanged between hospitals and regions need to be determined at the local regional level; optimal integration tools and techniques are not yet established.17

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To date, few studies have assessed the impact of HIT in the emergency setting. Overhage and colleagues31 evaluated the availability of outside hospital clinical records to ED providers and found a trend toward cost savings of $26 per encounter, with no difference in quality measures. Baumlin et al.6 and Shapiro et al.7 implemented an EDIS along with extensive process redesign at a busy, inner-city ED and found decreased patient throughput times and improved ED efficiency. Continued evaluation of EDIS is crucial, because some studies question the value of HIT, even suggesting that HIT may increase mortality.32,33 As HIT adoption and implementation progresses, we need to carefully evaluate how HIT affects health care costs, quality, efficiency, and regionalization of care. Research Questions 1. What is the status of prehospital and EDIS adoption and integration? 2. How will ‘‘meaningful use’’ policy affect the ED and EDIS adoption? 3. What are the challenges and success strategies for prehospital and EDIS adoption, implementation, and integration? 4. What are the effects of integrating prehospital information systems with an EDIS: on costs, quality, efficiency, and regionalization of care?

REGIONAL HEALTH INFORMATION EXCHANGE Recommendation 2 Relevant patient health information should be shared electronically across the entire health care delivery system. Background Health information exchange is the means by which health information is moved electronically throughout the health care system among otherwise unaffiliated health care stakeholders, including community and tertiary care hospitals, nursing homes, ambulatory practices and clinics, commercial laboratory and radiology facilities, pharmacies, private and public payers, and home care agencies. RHIOs provide the governance structure for these stakeholders to build regionally based network architectures and infrastructure to support HIE and interoperability services. HIE in its simplest form enables a clinical results review in a provider portal, allowing clinicians to view clinical information across the spectrum of organizations. There are also efforts to use XML-based standards such as the Continuity of Care Document (CCD)34 to facilitate the exchange of standardized health information directly among different vendor-based EHR systems by importing and exporting a summary document. Regionalization of care requires coordination among, and actual patient transfer between, these otherwise unaffiliated health care stakeholders. Information is often lost during these transfers, causing information gaps that may ultimately lead to medical errors or adverse events.35–38 As such, during these transitions of care patients are particularly vulnerable.39 HIE provides the means for patient health information to follow them

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as they move about the health care system, supporting regionalization through improved sharing of health information across stakeholders. Additional utility supported with HIE-generated data may help further support regionalization of care. These include ‘‘secondary uses’’ (use of clinical data from HIE to provide benefit for a secondary purpose): • Medication management: e-prescribing with pharmacies, formulary checking with plans, and medication reconciliation using claims and pharmacy data from pharmacy benefit management data aggregators like Surescripts (Surescripts, Alexandria, VA). • Event notification: i.e., automated notification to a PCP that his or her patient visited an ED. • Secure messaging and closed-loop referrals: HIPAAcompliant, secure electronic communications between providers that may also enable the generation of a request for referral to another clinician with a report then being sent back once the referral visit is completed. • Clinical decision support: automatically generated alerts to notify clinicians of drug–drug interactions, drug–allergy interactions, drug–condition interactions, and other safety measures based on clinical data available through the HIE platform. • Quality reporting: s Patient level: chronic disease management and the patient-centered medical home, allowing a PCP to manage individual patients or panels of patients.40,41 s Provider level: pay for performance, ranking provider performance, and often linking this to provider remuneration by payers using automated report generation based on clinical data from the HIE platform.42 s Organizational level: present on admission, core measures, and other quality assurance and regulatory requirements may be supported by data available through HIE.43 s Population level: support of a population quality data warehouse that allows the region’s public health agency to generate reports based on deidentified data from a HIE platform (e.g., what is the prevalence of diabetes and how well is a particular population being managed based on hemoglobin A1C and other clinical data available through HIE?). • Public health: s Automated reportable disease notification to the appropriate public health agency: every state has a list of mandatorily reportable diseases such as tuberculosis or syphilis. s Public health investigation: when a public health agency needs to gather more information based on a notification of a reportable disease. This allows ‘‘shoe-leather’’ epidemiology (going to the hospital and looking through charts) to become ‘‘armchair’’ epidemiology, with the investigator gathering clinical information through the HIE portal. s Biosurveillance: using detection algorithms and filtering large volumes of HIE-generated clinical data to detect disease outbreaks or bioterrorist attacks. • Research: s Clinical trials enrollment.

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Retrospective data analysis and data mining for hypothesis generation and cohort definition. • Industry s Clinical trials enrollment for Stage 3 drug trials conducted by pharmaceutical and medical device manufacturers. s Pharmacovigilance, also referred to as Stage 4 drug trials: after a new drug is released on the market, pharmaceutical companies are required to monitor for adverse drug events. Obtaining data though HIE might facilitate more efficient and less costly data collection. s

Current State According to the eHealth Initiative’s sixth annual survey in 2009, at least 193 HIE initiatives existed across the country, 57 of which reported being operational, up nearly 40% from the prior year.44 Although many RHIOs have had difficulties maintaining financial sustainability,45,46 new projects emerge each year and the federal government has now awarded $548 million to state-designated agencies under the State Health Information Exchange Cooperative Agreement Program, which is part of the Health Information Technology for Economic and Clinical Health (HITECH) Act provisions of the ARRA.47 The relevance of these projects to emergency medicine has been discussed in the literature48,49 and the involvement of emergency physicians in helping develop HIE-based services and helping improve workflow integration, adoption, and usage in the ED remain important.50 Health information exchange and HIT interoperability is going to be a key component in the ultimate goal of connecting small ambulatory practices (the HIT equivalent of ‘‘the last mile’’) and having EHRs in every nook and cranny of the health care system generating data, but we are a long way from having patients’ health information seamlessly follow them no matter where they travel within the health care system. Research Questions 1. What are the optimal methods for workflow integration of HIE in the ED and how can these efforts improve adoption and usage? 2. Can HIE help decrease resource utilization (e.g., duplicate diagnostic tests and potentially avoidable hospital admissions)? 3. Can HIE help improve safety, quality, and efficiency in the ED? 4. Can HIE save money, and to whom do the savings accrue—payers, providers, employers, patients?

WEB-BASED COLLABORATIVE TECHNOLOGIES Recommendation 3 Web-based collaborative technologies should be employed to facilitate patient transfer and timely access to specialists. Background As Web technologies have advanced, a distinction has been drawn between ‘‘Web 1.0’’—the older, static

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pages published by organizations and individuals—to today’s more dynamic pages featuring shared content, known as ‘‘Web 2.0.’’ While collaborative Web 2.0 technologies such as blogs and wikis have garnered publicity for their social implications, much has also been written about the potential for Web 2.0 technologies to improve health education51 and scientific communication.52 Web 2.0 technologies, where individuals and organizations can easily collaborate on documents and spreadsheets, and share data and status information, may be of benefit in efforts to regionalize care as well. Effective health care regionalization requires all participants to be seeking and transferring information, be it patient data, hospital capacity and diversion status, specialist contact information, or simply critical care protocols. While the communication of patient data has been discussed in earlier sections, other communication between practitioners and organizations is ripe for the improved electronic collaboration that is possible with Web 2.0 tools. Current State The benefit driving regionalization is that patients in outlying care centers gain access to specialists and their facilities, while higher-level care centers experience a wider catchment of patients for their services. With this mutual benefit, one might expect well-worn paths regarding patient transfer or consultant contact information. This is generally not the case—the rules governing how patients move up and down the system are often not standardized or easily referenced, and the means to access specialists is notoriously unpredictable. Patient transfer protocols may be nonstandardized within a regional health care system (or between systems) for a variety of reasons. The evidence informing these protocols is subject to change, as are the capabilities of various centers and even the distances between centers (as some close and others go online). Yet when critical-care physicians were surveyed on the barriers of implementing regionalization, the importance of objective criteria for transfers was rated as very high.53 While the challenges regarding transfer protocol development for various contingencies have been noted,54,55 little has been written about how these transfer protocols are disseminated and referenced. Although handbooks, manuals, posters, and sheets can be distributed easily enough, a Web-based solution for changing guidelines makes more sense, from the perspective of ensuring that everyone is on the same page, as it were. While sharing hospital protocols over the Web is not a new idea,56 it is only recently that peerreviewed literature has described computer-based guideline sharing across a region,57 although the described technique employed CD-ROM technology to facilitate standardization, not explicitly regionalization. Although more hospital transfer protocols are finding their way onto the Web,58 the use of collaborative Web-based authoring tools has not been reported. Web-based tools such as Google Docs or Wikis use offsite servers (‘‘in the cloud’’) to allow privileged users to upload and modify documents. A log is kept of changes, and the files—detailing protocols, contact information, and links to the literature—can be viewed

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by anyone or by a restricted list of practitioners and administrators. A system such as this is simple enough to allow speedy modification of documents, by consensus, without the cumbersome involvement of hospitalbased information technology personnel. With increasing adoption of easily accessible and referenced guidelines, it should become possible to study guideline adherence regarding the transfer of patients. As has been the case with widely adopted intrahospital and national guidelines,59 studies on adherence should inform quality analyses, patient and provider satisfaction surveys, and outcomes studies and should inform future guideline development. While all facilities must standardize and agree upon patient transfer protocols, it is incumbent on receiving facilities to make their status and availability known. While communicating ambulance diversion status to EMS is done through dispatchers,60 subtler markers, like critical care bed availability or operating room usage, are difficult to broadcast to select audiences. Often, receiving hospital status is communicated through such inefficient means as medical control dispatches or through phone calls at the initiation of patient transfer. The efficacy of these approaches has not been studied, although a survey of intensivists suggested that overwhelmed tertiary care facilities were a significant barrier to implementing regionalization.53 Web 2.0 technologies have given rise to microblogging services such as Twitter, which enables users or institutions to send brief status updates or website links. Several hospitals have already adapted this technology to broadcast ED waiting times61 to followers on Twitter. One can imagine cheaply adapting this to broadcast (to a closed network of regional subscribers, if desired) a hospital’s ambulance diversion status or number of available pediatric intensive care unit beds or operating rooms. Clinicians and administrators attempting to facilitate a patient transfer could view a regional network’s status updates online, rather than place a series of time-consuming phone calls. Just as several barriers exist for developing and implementing patient transfer protocols, so too are the reasons for difficult specialist access varied. Specialty providers often swap coverage, update contact information, change affiliations, gain and lose privileges at different hospitals, and cover different insurance plans. Keeping an up-to-date list of available providers on a given night for specialties like orthopedics, neurosurgery, and otolaryngology has become increasingly difficult62,63 and has led to longer patient wait times, practitioner and patient dissatisfaction, avoidable transfers,64,65 and likely, bad outcomes. Online, collaborative database solutions may be up to the task of matching emergency physicians with an ever more selective array of specialists. Although not studied explicitly for regionalization, software such as AMiON (AMiON, Bethesda, MD) is seeing increasing use and allows multiple administrators at different sites to upload schedules that can be accessed by physicians, staff, or operators. It may be adaptable to service entire regions and prove superior to current methods that frustrate patients, providers, and off-service specialists.63

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Beyond the aforementioned benefits of adopting Web 2.0-style collaborative computing solutions for sharing management guidelines, broadcasting hospital ward status alerts, and assisting specialist contact and scheduling, there exists an additional benefit. These technologies all have the ability to track changes and create logs—which can be invaluable in quality analyses and when pursuing a research agenda. Research Questions 1. What data, and how much, should inform decisions to transfer patients or consult specialists? 2. Does adherence to agreed-upon regionalization protocols improve outcomes? 3. Do such protocols improve provider satisfaction? Patient satisfaction? 4. What can be learned from retrospective quality assurance–style review of transfers and consults?

PERSONAL HEALTH RECORDS: ENABLING CONSUMER MANAGEMENT OF HEALTH DATA Recommendation 4 Personal health record adoption should be considered as a way to improve patient health. Background Circa 1992, Pierre Omidyar created a website for a girlfriend who needed a way to trade collectible Pez candy dispensers. We now know that ‘‘website’’ as eBay, with a $20B market capitalization, more than 12 million sales per day, and 750,000 ‘‘eBay entrepreneurs.’’ It is another example of the age-old adage, ‘‘If you build it (and it meets a compelling need) they will come.’’ While hospital-based EHRs have made electronic health data more prevalent, sharing these data outside hospital walls has been a challenge. Regulations, such as those resulting from HIPAA, security ⁄ privacy issues, and general fear of liability have created certain challenges for sharing of protected health information, but many of these hurdles have been overcome. It is also becoming evident that allowing patients to view their data has few, if any, untoward consequences and many more potential benefits.11 In fact, HIPAA and ARRA require health data to be shared with patients, including electronically. What has been lacking for consumers is similar to what has been lacking in other forms of health data sharing, the infrastructure, i.e., connectivity, standards, and authentication systems. Not surprising, the first wave of PHRs were ‘‘tethered’’ to individual EHRs. While there is some utility to this approach, the lack of portability limited its effect. Current State Now, 15 years after eBay transformed personal commerce, a similar wave is transforming personal health care. In much the same way, emerging technologies are enabling consumers to take more active roles in managing their personal health data, and their health as well. Often called PHRs, these efforts are now being driven by mainstream vendors such as Microsoft, Google, Intel, WebMD, and others.

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More recently, Continuity of Care Records and the CCD have solved the standards challenge and connectivity is being addressed in ways similar to online commerce. Various PHR and health ‘‘applications’’ are now available and continue to gain momentum. With home medical device monitoring and wellness applications, chronic disease becomes ‘‘chronic wellness.’’ Congestive heart failure patients avoid readmission by automatically monitoring their daily weight. Diabetics more closely manage blood sugars via a cell phone–enabled diet application and integrated glucometer. Wellness is enhanced with various online applications that leverage rich data drawn from all data sources. The final challenge is automation of data input from the many disparate systems (e.g., hospital EHRs, diagnostic labs, e-prescribing systems). Progress is being made, although critical mass may still be 5 or more years away. The future of health care is ‘‘connected,’’ and the consumer will be at the center of this revolution. Research Questions 1. Do PHRs improve health? 2. What are the barriers to consumers using PHRs? 3. Will consumers shop for health care in markets that have more data available to them? 4. Will these data (e.g., up-to-date medication lists, allergies, problem lists, personal physicians, old electrocardiograms [ECGs], laboratory tests, x-rays, advanced imaging) being available immediately, online, and at the point of care worldwide transform the practice of emergency medicine?

TELEMEDICINE AND TELECONSULTATION Recommendation 5 Emergent telemedicine and teleconsultation should be employed and studied as a likely means of reducing costs and expediting care in regionalized health networks. Background Telemedicine—the use of audiovisual media for the purpose of consulting specialists—has been a part of both emergency medicine and regionalized care for decades.66 Every time an emergency physician picks up a phone to call the local poison center about a patient, telemedicine is employed in a regional health network. While telephone consultations are a part of everyday emergency physician practice, more elaborate forms of telemedicine are becoming possible, with the use of video and computer equipment to help specialists diagnose and manage stroke, orthopedic injuries, cardiovascular disease, critical care units, trauma stabilizations, and more. With dropping costs and new technologies, more options for remote consultation will be possible in regionalized networks of care. Current State Many uses of telemedicine technology in emergency settings around the world have been described, with most studies lending credence to the notion that tele-

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medicine consults can reduce hospital transfers and admissions, expedite patient care, and let specialists cover a wider catchment area. These smaller studies await the definitive trials that regionalized networks can provide.67 Toxicology. Because this form of telemedicine is so familiar and available, the only studies regarding its efficacy come about during natural experiments surrounding budget cuts. These analyses suggest that every dollar spent on manning phones for patient calls saves more than $7 in avoided health care charges.68 Ophthalmology. Videoconferencing has been found to be safe, accurate, and efficient for managing referrals, although in one study more follow-ups were noted after telemedicine than after face-to-face encounters.69 Orthopedics. Older studies of digitized films of pediatric bony injuries sent to referral centers were found to have comparable sensitivity and specificity to plain films for diagnosis of fracture.70 With the transition to picture archiving and communication systems (PACS) for routine viewing of films, discrepancies seem less likely and remote diagnosis has flourished. Telemetry. EMS remote activation of cardiac catheterization laboratories has been actively studied in recent years, with data suggesting that recognition of ST-elevation myocardial infarction by EMS personnel, emergency physicians, or even ECG algorithms is sensitive and specific enough to warrant activation. The savings in door-to-balloon time associated with this form of telemedicine are persuasive.71,72 Stroke. A recent review of stroke telemedicine found compelling evidence for remote stroke evaluation in the hyperacute and ED phases, with comparable interrater reliability to bedside neurologists using the National Institutes of Health stroke scale.73 Teleradiology of head CT and brain magnetic resonance imaging was also deemed feasible and effective. The authors noted less evidence and several caveats before remote administration of thrombolytics for stroke could be recommended. Dermatology. While seemingly a natural fit, dermatology studies of telemedicine have often employed storeand-forward technology for evaluating slow-growing, rather than emergent, skin complaints, with ambiguous results.74 Beyond these one-on-one consultations facilitated by telemedicine, the potential exists for remote monitoring and management of multiple trauma or critically ill patients by remote providers. Telemedicine systems for this purpose were described decades ago, but are now seeing implementation in military75 and rural settings,76,77 where on-site nurses, therapists, emergency physicians, and nonintensivist physicians were guided by remote intensivists or trauma surgeons. These trials have demonstrated the feasibility of remote monitoring to improve outcomes over the exist-

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ing systems of care, as well as cost savings in prevented transport.78 They demonstrated that when a teleintensivist supplemented existing staff coverage of critically ill patients at an integrated care network, intensive care unit mortality and length of stay decreased, as did average case cost. Beyond remote intensivist or trauma specialist coverage, this model has been expanded to include telepharmacist coverage, which has been shown to enhance therapeutic intensive care unit interventions.79 While successful trials of telemedicine continue to mount, few large studies have assessed whether telemedicine results in cost savings or decreased resource utilization. However, given the lack of standards in telemedicine evaluation, and the changing nature of technology, it is not clear whether such studies will retain meaning over time. For instance, a phone call and remote PACS access may constitute as effective an orthopedic teleconsult as that obtained from an expensive videoconferencing system. Furthermore, that same expensive videoconferencing system for linking emergency physicians to specialists may be rendered obsolete by free Skype software on computers and smart phones. Still, some data exist regarding the utility of telemedicine initiatives. Fox et al.80 reported success with decreasing ED visits for adolescent prisoners by implementing a telemedicine strategy. Another area showing promising cost savings through telemedicine is prescreening patients before air medical transport. In a prospective study of patients transferred from outer islands to Taiwan, physician video teletriage helped reduce what turned out to be clinically unnecessary air transfers, with significant cost savings.81 In Georgia, where nursing home patient transfers and ED evaluations frequently exceed $2000, frustration with the current system has spurred innovation, funded by the ‘‘margin’’ of potential savings. The Medical College of Georgia ED has established ‘‘connections’’ to 10 area nursing homes, with the expectation that there will be consultation available for real-time advice on whether transfer is appropriate. The participating institutions are rural and remote from the central academic center, and although all expressed hesitation with the project at first, the initial post go-live experience at the Medical College has been enthusiastic. Preliminary data indicate a significant reduction in unnecessary transfers (B. Janiak, unpublished data). Examples like this highlight the need for more, and larger, outcome studies to assess the effects and cost benefit of telehealth applications, in terms of improving quality of care for select populations and larger care areas. In addition, more research is needed to demonstrate the ability of telehealth tools and technologies to facilitate and extend the reach of central care provider teams.82 Perhaps most importantly, the National Institutes of Health should develop and ⁄ or strengthen strategic partnerships with other funding agencies with overlapping or complementary interests to accelerate interdisciplinary research in this rapidly evolving but complex and relatively understudied field.

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Research Questions 1. Which telemedicine initiatives are safe and effective when compared to bedside evaluations? 2. For remote critical care monitoring and trauma management, what is the optimum constitution of onsite and telemedicine caregivers, and how many patients can be cared for safely? 3. What are telemedicine’s outstanding insurance and reimbursement issues that still exist in many states? 4. What network telemedicine model will work best to achieve cost reduction and maintain quality of care?

CONCLUSIONS Regionalization has great promise to expand the quality of care with efficiency and fairness. Electronic collaboration, emanating from EDs, will be essential to realize this promise. As the nation responds to legislative incentives to improve implementation of electronic health records, an opportunity exists to study and implement the existing technology to further our networks of regionalization. Expanding electronic collaboration may lead to improved care coordination, better outcomes, and overall reduction in health care spending. The research agenda laid out in this article represents a framework for moving forward in regionalization using the support of the world of information technology. Dr. Baumlin is currently a fellow with the Greater New York Hospital Associate ⁄ United Hospital Fund Clinical Quality Fellowship Program (CQFP).

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