First study of emergency care for an entire state finds care isn't always local

December 20, 2011

INDIANAPOLIS -- The first study to examine patterns of emergency care for an entire state has found that 40 percent of emergency department visits in Indiana over a three-year period were by patients who visited more than one emergency department. This finding challenges conventional wisdom that patients are tightly bound to health care systems and tend to repeatedly visit local facilities.

The Regenstrief Institute study, "All Health Care Is Not Local: An Evaluation of the Distribution of Emergency Department Care Delivered in Indiana" has been honored with a 2011 Distinguished Paper award at the AMIA Annual Symposium and has been published in the Proceedings of the AMIA 2011 Annual Symposium. AMIA is a professional society of health care professionals, informatics researchers and thought leaders in biomedicine, health care, and science.

The Regenstrief study reports that nearly all emergency departments in Indiana shared patients with nearly every other emergency department. The high degree of connectedness between emergency departments had not been previously recognized at this scale, according to the researchers.

"Our findings provide critical, previously unrealized information to policy makers as well as those, like ourselves, who are designing strategies and technology to link medical information electronically. These numbers challenge premises upon which health information exchange policy and technology have been based," said the senior study author, Regenstrief Institute investigator Shaun Grannis, M.D., M.S., associate professor of family medicine at the Indiana University School of Medicine.

"Since EDs can't predict when patients will appear or know in what other places they have been seen, all EDs need instant access to information from wide swaths of geographic areas and actually the entire nation," said Dr. Grannis, who directs the Indiana Center of Excellence in Public Health Informatics, one of only four Centers for Disease Control-funded public health informatics centers in the nation. Data from the Indiana Public Health Emergency Surveillance System was used in the study to determine where emergency department visits were occurring.

As patients in the emergency department often forget key details or are too ill or injured to provide relevant medical history, medications or allergy information, immediate access to their complete medical records is critical to providing appropriate care.

"What may appear to be a simple problem is no longer simple when someone comes in for a second or third ED visit for the same issue. You are no longer thinking earache, you are thinking possible bone infection. Knowing that a patient who comes to the ED with chest pain had a recent clear cardiac scan will make a difference in treatment," said Regenstrief Institute investigator John T. Finnell, M.D., M.S., associate professor of emergency medicine at the IU School of Medicine, who is an author of the new study. He is an emergency medicine physician.

The researchers were not surprised by the large volume of visits to emergency departments across the state. Approximately 2.8 million patients generated 7.4 million visits over three years. But the wide range of the number of visits per patient -- from one to 385 -- was unexpected.

"Although our findings were specific to Indiana, ED use in other states is likely to be quite similar because there is nothing particularly unique about emergency care delivery in Indiana," Dr. Finnell said.
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The study, also co-authored by former Institute investigator and former director of medical informatics J. Marc Overhage, M.D., Ph.D., was funded by the Centers for Disease Control and Prevention through the Indiana Center of Excellence in Public Health Informatics. James Egg and Shahid Khokhar of the Regenstrief Institute extracted and processed the millions of electronic messages analyzed in the study.

Dr. Grannis and Dr. Finnell are now further characterizing the geospatial relationships between the patient's home address and the specific emergency departments visited. This information could be used to help predict which types of patients are more likely to require additional services to improve their overall health.

Indiana University School of Medicine

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