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The Truven Health Blog


The latest healthcare topics from a trusted, proven, and unbiased source.


Emergency Department Physicians Ordering Unnecessary Imaging Tests


By Byron C. Scott/Thursday, April 16, 2015


As a residency trained, board certified emergency medicine physician who practiced for over 20 years, I was not surprised entirely by a recent Health Leaders’ article stating that ED physicians order unnecessary imaging tests, based on a research article published in Academic Emergency Medicine in April of 2015.    

There is no question that as a practicing physician in the emergency department, you try to make decisions based on sound evidence-based medicine.  The reality is that other factors are constantly influencing decisions, such as patient demands, other physicians involved in a case, liability issues, and just not wanting to miss something that could harm the patient.  On multiple occasions during my career as a medical director and practicing emergency department physician, I have seen patients with a history and physical exam that did not justify ordering an additional imaging test,  however, medicine is an art and often instinct plays into decisions.  If emergency department physicians ordered tests based exclusively on what evidence based medicine supports, many emergent diagnoses would be missed causing a poor outcome for the patient.  The assumption is that not ordering a test because the evidence does not support it will protect you in a malpractice lawsuit.  However, those who have practiced medicine for years know this is not always the case.  

The best approach for now is to continue to look at innovative ways to engage patients and physicians.  For physicians, this will include having real-time prompts and reminders tied into the electronic medical record ordering system, based on evidence based guidelines that are easy to use and access.  Today, patient education and engagement tools are mostly used outside an acute emergency department, but perhaps these tools with their easy-to-use clinical information, statistics, and images could also provide real-time education for the patient to help explain why certain imaging tests are not required.   Tort reform may be one way to influence excessive ordering of diagnostics test but I believe the clinical instinct and art of medicine, as well as evidence based guidelines and patient education, are important to achieving the best outcomes.

Byron C. Scott, MD, MBA, FACEP, FACPE
Medical Director, National Clinical Medical Leader

 


The Newly Insured Don’t Turn into Primary Care Physician (PCP) Loyalists Overnight


By Linda MacCracken/Tuesday, August 19, 2014
Linda MacCracken imageWhen looking at the impact of the newly insured, the Philadelphia market’s experience of an 8% rise in emergency department (ED) use is notable. Moving from uninsured to insured status may happen in a day, but new health service use habits take time. The impact of the newly insured – via Medicaid expansion or private exchanges – is still unfolding.

Truven Health forecasts on the impact of the newly insured mirror the statistics noted in the Philadelphia Inquirer article, “With Health Law, ERs Still Packed.” In fact, young adults and children are more likely to use an ED when they have insurance versus when they had less insurance. Surprisingly or not, children, Millennials and young Gen Xers are not primary care physician (PCP) loyalists.

Join our webinar “What to Expect from the Newly Insured” to get highlights on what to expect, tips on how to prepare, and how to realize higher profits and deeper customer engagement.

Linda MacCracken
Vice President, Advisory Services

Pediatric Emergency Department Quality of Care: A Focus on Pharmacists and Drug Therapy


By Linda Elbers/Wednesday, July 23, 2014
Linda Elbers imageListening to National Public Radio (NPR) on the way to work recently, I heard a very interesting report about Children’s Medical Center in Dallas incorporating full-time emergency department (ED) pharmacists to ensure appropriate and optimal drug therapy is provided to their patients in the ED setting. As a pediatric-trained pharmacist, anytime I hear about organizations embracing the pharmacists’ role in doing even more to support safe and effective drug therapy in this patient population, it’s particularly exciting. And this information was timely, as my colleague Tina Moen, Chief Clinical Officer for Truven Health, just shared her thoughts about the expanding role of the pharmacist in a recent blog post. While pharmacists have known for some time that we have a great deal to contribute to improving patient safety, it’s wonderful to know that others are taking notice now more than ever.

Important, key organizations such as the American Academy of Pediatrics (AAP) and Emergency Medical Services for Children (EMSC) are focusing much time and effort on improving pediatric services in U.S. emergency departments. This isn’t just for pediatric-specific emergency departments, but for any ED that will see neonatal and/or pediatric patients, whether frequently or infrequently. It’s estimated that up to 25 percent of all ED visits in the U.S. are pediatric patients, and approximately 90 percent of children’s visits to the ED are in non-pediatric hospitals.

EMSC – an organization that works to promote emergency medical services (EMS) and trauma system development at the local, state, regional, and national levels to adequately prepare for care of children – has developed 60 ED pediatric performance measures that comprehensively cover a broad range of assessable activities related to pediatric emergency care. I recommend visiting www.emscnrc.org to learn more about this resource.

As you would expect, some of the 60 EMSC performance measures and their potential outcomes are associated with drug therapy. For example, “timely treatment with anti-epileptic drugs for patients in status epilepticus” is one of the performance measures. The numerator for this performance measure is the number of patients who received an anti-epileptic drug within 10 minutes of arrival, and the required data elements include medication name, patient arrival time, and medication receipt time. As a pharmacist, however, there are many additional steps in this arena to further care and improve outcomes, simply by applying a medication-focused lens. For instance, while the patient may receive an anti-epileptic medication within 10 minutes of arrival, to assess the efficacy of the therapy, we need to know additional information and should do further assessment, including asking:
  • Did the medication provided actually resolve the seizure?
  • Was the right drug administered for this patient?
  • Was the correct dose prescribed?
  • What resource was used to determine the dose? How was it calculated?
  • Was it administered correctly?
Without this further evaluation of medication practice, it’s difficult to affect outcomes and quality.

Other EMSC performance measures address pain management and sedation (e.g., the effective pediatric procedural sedation, treating and reassessing pain). While there are criteria for assessing adequate sedation or adequate pain relief, again, as a pharmacist, it’s clear that more information would lead to marked advancement in patient care. For example, if there were additional documentation required regarding the drug(s) used, the dose(s) used, the route of administration, etc., this would help to assess outcomes. As such, the additional detail can assist in developing protocols to assure adequate sedation or pain control in the majority of situations – a problem patients across the country routine indicate is an area of patient dissatisfaction in HCAHPS results each year. And this additional detail could identify inconsistencies or inadequate drug therapy, including drug dosing that leads to inadequate/ineffective sedation or pain control.

As the NPR story pointed out, not all hospitals will have the resources to hire a full-time, or even a part-time, ED pharmacist to manage pediatric drug therapy in the ED setting. However, a pharmacist’s focus and input have the potential to contribute greatly to improved pediatric emergency care. What has your ED done to be better prepared to treat children? How are pharmacists contributing to better emergency care? Let us know what first steps you have taken, or would like to take, to help your organization and others meet the mark for pediatric and neonatal care in the ED.

Contact me on LinkedIn.

Linda Elbers, Pharm.D.
Clinical Solution Advisor Neonatal/Pediatric Evidence-Based Practice

Health Information Exchanges Provide Valuable Information to ED Physicians


By Byron C. Scott/Wednesday, March 19, 2014
Byron Scott imageIf you polled every physician, especially emergency medicine physicians, in the country, and asked if it would be valuable to have access to patient data from Health Information Exchanges to help prevent unnecessary admissions from the Emergency Department (ED); the answer would be 100% yes. I applaud the study by Joshua Vest PhD at the Weill Cornell Medical College to continue the national debate and increase the awareness about the importance of health information exchanges to reduce costs and unnecessary care in the country. The state of New York and others have been on the forefront to invest in the exchanges.

I realize that many are afraid to allow access to health records across a large spectrum because of HIPAA concerns, but I can tell you that as an emergency medicine physician, it’s safer for the patient. Emergency medicine physicians are the gate keepers and the ultimate patient advocate. If you become a patient in the emergency department, your physician will need to access records and diagnostic test results to avoid performing repeat tests and creating unnecessary readmissions. Many times a patient cannot remember what was done, where it was done, or even the results of the test performed. Yet, the patient is brought to a hospital in the middle of the night by ambulance to a hospital in town they have not been to. Yet, they had a vital piece of information during another stay that could mean the difference in whether additional test or admissions are performed. Even in the age of electronic medical records and advanced technology, it’s still challenging to try to get information from an unaffiliated hospital, clinic, or doctor’s office.

I actually worked a 12-hour shift in the Emergency Department just last week. I saw a patient who suffered an injury but went to an Urgent Care facility just a few hours prior to seeing me in the Emergency Department. The patient had an x-ray at the unaffiliated clinic, and therefore I didn’t have access to this information. It was a diagnostic test I needed to visualize to make the correct treatment and disposition decision. Fortunately, the urgent care clinic made a copy of the x-ray on disc and gave it to the patient. Thankfully, he brought it with him, preventing me from ordering another x-ray, adding to the cost of his treatment, and exposing him to additional radiation exposure. I was lucky in this scenario, but countless physicians (me included) could tell you stories where if we had access to information quickly, we could not only reduce cost, but improve customer service to the patient. 

We must continue to educate and support the need to Health Information Exchanges to improve safety, reduce cost, and improve efficiency. This further buoys the conversation about Population Health and the continued need for integration of clinical and administrative data on a real time basis.

Byron C. Scott, MD, MBA, FACEP, FACPE
Medical Director, National Clinical Medical Leader

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