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In Alameda County, A Big Data Effort To Prevent Frequent ER Visits

Tilted, full frame image of a gray and red sign at a hospital that says the emergency room is to the right and the main entrance is to the left. The sign has white letters and arrows. The image shows the separation between entering a hospital through the entrance or being brought to the emergency room.

Almost every day, a patient comes into Dr. Arthur Sorrell’s San Francisco emergency room still wearing a wristband from another hospital nearby.

“There are folks who have a life of going from emergency department to emergency department, and that’s how their day is spent,” said Sorrell, an emergency physician and administrator at Sutter Health. “It’s sad and tragic, but that’s what happens.”

The wristband is at least a hint.

Without it, emergency room staff often have no idea they are sharing patients with other hospitals just a mile away. So they treat those patients completely independently, often repeating tests unnecessarily, assigning them multiple case managers when only one is needed and offering contradictory advice.

Some patients have chronic health problems that send them repeatedly to the ER, while others are seeking food, a warm bed or someone to talk to.

Even if ER staff do know about visits to other hospitals, sharing information about the patient is a struggle. “I have to tell my unit coordinator to call over to the other hospital and have them fax over the records,” said Sorrell. Sometimes, a 50-page fax will arrive, which Sorrell must sift through while juggling dozens of other patients.

But that vexing reality may soon change for hospitals in Alameda County, as they team up to share patient health records and other data in real time among their emergency departments.

So far, their partnership includes four Sutter Health hospitals and two Alameda Health System hospitals. Since the program began on March 31, Alta Bates and Highland Hospitals have learned that they shared more than 2,000 patients, and over a third of them made six or more ER visits in the past year.

The hospitals share a system called PreManage ED, which tracks all of their ER patients. When an emergency department enters a patient’s name into the system, it gets an alert if that patient has visited other hospitals. If so, the emergency department staff can view information about the patient’s recent treatment and find out whether he or she already has a case manager somewhere else.

The system can also benefit the many patients who end up visiting multiple hospitals. If a patient already had an x-ray, CAT scan or other test at one hospital, for example, the shared database can help ensure he or she doesn’t get the same test again.

Some experts, however, say competition among hospitals can be a deterrent to data sharing.
Whether a hospital is willing to share information with competitors depends on how it gets paid, said Dylan Roby, an assistant professor at the University of Maryland School of Public Health.

Hospitals that want to avoid having their payments reduced by federal penalties for readmissions, for example, have a strong incentive to collaborate in order to avoid unnecessary ER visits by Medicare patients. Hospitals participating in collaborative care networks that are paid monthly amounts for patient care also have an incentive to share information.

“But it’s not always in [hospitals’] financial interest to share data about patients,” said Roby. Facilities that still depend on fee-for-service payments they receive for each individual patient visit, for example, may prefer to fill their beds rather than collaborate with competing hospitals.

PreManage ED already is being used by hundreds of hospitals nationwide, primarily in the Pacific Northwest. Twenty California hospitals use the system, and dozens more are in talks to do so.

But what sets Alameda County’s effort apart is that it also plans to include community health clinics and other social service organizations, so they too will receive alerts from the hospitals when their patients seek emergency care.

The idea for the collaboration arose in 2015 from the experience of a single patient — a 57-year-old Oakland woman with a history of mental illness and chronic substance abuse. In just three years, the woman visited local emergency rooms more than 900 times.

“We really thought we were her favorite hospital. She knew the names of everyone, from the doctors to the security guards,” said Tracy Schrider, who coordinates the care management program at Alta Bates Summit Medical Center in Oakland and had assigned the woman a social worker. “We had no idea she was already in a case management program and was going to Highland even more than she was going to us!”

The teams at the two hospitals sent the woman to different agencies and gave her conflicting advice, Schrider said. “Everybody meant well. But she was being referred to three different substance abuse clinics and two different mental health clinics, and she had two case management workers both working on housing.” It was not only bad for the patient, it was also a waste of precious resources for both hospitals, Schrider said.

Elsie Kusel, an emergency medical services coordinator for Alameda County, helped discover the connection. The patient had taken hundreds of ambulance rides in the previous year.

”We brought everyone to the table. There were more than two dozen people in one room, talking about one person,” Kusel recalled. They included representatives of both hospitals, several community-based organizations, the paramedics, the Berkeley public health department and the fire department. All of them had helped care for the woman at some point — they just didn’t know it.

The PreManage ED project will make patients like that 57-year-old woman known to all the providers who can help coordinate her care, wherever she seeks treatment.

“We’ve made visible a group of patients with unmet needs throughout our community,” said Sorrell.

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