What to expect when Virginia’s ED care coordination system launches this summer. Our interview with Washington ACEP’s Stephen Anderson, M.D., on the state’s successes – and challenges – with EDIE.
This summer, Virginia will implement an Emergency Care Coordination Program to link all hospital emergency departments across the Commonwealth. The backbone of the program is a software system will facilitate real-time communication and collaboration with the goal of providing seamless and improved patient care – and, in the process, reduce unnecessary medical costs and ED visits, and put frequent ED visitors on a path to finding the help they need.
Virginia follows in the footsteps of 13 states that have linked EDs statewide to improve patient care and target high utilizers via a health-information exchange platform created by Utah-based Collective Medical. The first to implement the company’s Emergency Department Information Exchange (EDIE) was Washington, which in 2011 had its hand forced by Washington State Health Care Authority to limit non-emergent visits to the ED to three per year in an effort to reduce a $32 million Medicaid deficit. This “flawed state policy,” as Washington ACEP president Stephen Anderson, M.D. puts it, would have been a clear violation of Prudent Layperson – and at a minimum was simply bad for patients, hospitals, and physicians.
In response, provider and hospital groups in Washington proposed Seven Best Practices to coordinate efforts and better manage ED services to reduce over-utilization without denying care or coverage. The Governor gave them only three months to implement the system, the backbone of which was EDIE, a software product that was ingrained into emergency department EMR (Emergency Medical Record) systems statewide to proactively notify physicians when patients arrive who require a second look.
In the first year of implementation – 2014 – the EDIE helped Washington state save approximately $33 million, along with numerous other benefits both monetary and medical. So what can Virginia expect as we move forward into this new world?
Virginia ACEP was fortunate to sit down with Dr. Anderson, who was at the helm of Washington ACEP when EDIE was implemented and has been a major proponent of the system, which is endorsed by ACEP.
VACEP: So most states get years, but you had an EDIE system up and running in only three months?
Anderson: When your head’s in a guillotine, you’d be surprised how fast you’ll work.
How has implementation been in the years that have followed?
One word: game-changer.
How long did it take for EDIE to reach Washington’s hospitals?
Within six months, we had essentially 94 out of 97 hospitals up and running. Everyone was in soon after. We geared up fast, and we got literally almost 100% buy-in from every doc in the state to make this happen. They wanted this tool.
Where has the program been a success?
The super-utilizers, who we define as people who came to the ED more than five times in a year, is where the real money savings was found. It actually wasn’t in the people that came once or twice, or the ones that are coming to the ED 50 times or more in a year, who are usually there for a warm place to stay for the night or to sober up; they’re not huge expenses.
But people from about five visits a year to about 15 visits a year usually have one of those diagnoses that kind of vexes all of us: things like undifferentiated abdominal pain, headaches, chest pain – the things that are potentially really serious but are not being well coordinated. We really thought that if we knew up front that the patient was somebody who had already had visited an ED elsewhere, or might already have a case management plan at some other hospital, that if we just shared it across the board they would get people better care and really bend the curve.
In the first year we did this, we cut down on the visits by the high utilizers by 15 percent. That’s pretty significant.
How does EDIE impact your job as an emergency physician?
It really changes the whole flow. We’re now up-front notified that we have an at-risk patient. What [EDIE] is really about is finding people that are at-risk for opiate addiction, other drug addictions, mental health disorders, diabetics who are poorly controlled, COPDers that aren’t well controlled, and all those other diseases that I say we manage but we don’t cure. We identify these people and give them a case management plan right up front. If instead of getting a different treatment in every hospital by every provider that sees them, EDIE just tells me, “Here’s where they’ve been, here’s the things that work for the – do this.” Patients like it, doctors like it.
Take for example a poorly controlled diabetic, in your ED for the fifth time in recent months. How are you changing his or her life?
Number one, I need to know that they’re poorly managed to know that I’m dealing with that issue to begin with. Up front, it puts me on alert that this a high-risk patient. I need to stop and take the time to figure out what isn’t working for this person.
Second, if there is something that works, it hands me the case management plan. EDIE case management may cut down on me having to do imaging studies, it may cut down on me having to admit them to the hospital – which is a huge expense. The big change in cost is being able to manage them and sending them home, versus having to admit them to the hospital. That’s where the economics skyrocket.
On average, how many EDIE alerts are you seeing in your patient population?
In Washington state, and in Oregon, and in a lot of the states that are up and running (with Collective Medical’s platform], we’re now realizing that around 80 percent of the people have an EDIE alert [for] either a concomitant mental health issue or a substance abuse issue. And if you don’t address that, then you’re probably never going to get to the bottom of their recurrent abdominal pain, their recurrent chest pain, their recurrent headaches.
You need to tie them into a primary care doctor that understands that they’re just coming back to the ED over and over again. You need to find out that they’re not going to their doctor because they work two jobs, and they can’t get in during office hours, or they don’t have a cell phone to make an appointment. The list goes on and on, and when you actually start to investigate some of the social barriers as well as the medical barriers, you start to come up with a plan that coordinates their care better. Instead of just kicking them out with no follow-up plan, you jump through the extra hoops to try and prevent it from being a revolving door.
EDIE seems sets in motion the idea of getting case management involved in an ED to figure out how we stop the behavior.
You start realizing that … this may be the first time that you’re seeing them, but they’ve been at nine other hospitals before you. When somebody comes in and they say, “I’ve got the worst headache of my life, it just hit me, it’s terrible,” and I would normally think, “Oh, I’ve got to CT scan you. This could be a head bleed.” Then I can pull up EDIE and find out they had the same complaint six times in the last three months. They’ve had three CT scans already, they’ve all been normal, they’ve been treated without CT scans and they’ve lived. So this tells me that maybe I don’t have to CT scan them again.
Part of the promise of EDIE is a cost savings. What have you seen in Washington state?
We saved the state $33 million in the first year with this program. That’s real money in a state the size of Washington. In the middle of an opioid epidemic, just identifying these people up front was enough to cut our prescriptions down by 24%. That’s continued to go down since then.
With any new program, specifically using technology, there are challenges to implementation. What hurdles might other states such as Virginia face when adding EDIE?
Definitely the biggest challenge is getting your IT departments integrated and up and running in your hospital. It only takes about one day of work by an IT person to do this. But it’s finding time for the IT guys to do it, because the IT guys are all overwhelmed, they’re all in the middle of a Cerner update, or an Epic update, and they’ve all got 17 other things on their priority list.
And I assume getting staff to use the system is another hurdle.
Correct. You have to get your staff to know that it’s there. It’s a new tool, but it’s not an entirely new system because it’s integrated into their EMR setting. Before I had EDIE, I could comb through old records, I could call another hospital and try to get the records, I could spend a long time trying to cull through to figure all this out.
EDIE shows up as an icon in your EMR, so you’ve got the patient name, a room number, a chief complaint, vital signs, what time they logged into the ED, whether they’re lapsed or pending. And then some have an EDIE alert. It helps me set the stage – I take a quick look and I’m set. Once it goes into your work flow, the benefits just keep growing and growing.
And the third challenge?
Getting case managers in your Emergency Department engaged with EDIE. In the old days, the only people that got to talk to a case manager were people that had been hospitalized and were being sent home from inpatient care. If you really want to make a difference with case management, you put case management into the Emergency Department, because that’s where your high-utilizers and high-risk patients end up. The huge savings economically and the huge advantage health-wise is if you can prevent those people from having to be admitted, earlier.
Is EDIE creating more demand for case managers, or are you just shifting these jobs from the inpatient care into the ED setting?
It’s creating a bigger demand for case management. Every hospital in Washington state now offers case management to their EDs. That wasn’t the case before. Most smart CFOs anywhere in the country understand that having case managers makes a difference on the bottom line. The cost of that new case manager is far less than what it costs to keep people coming back.
It seems like for EDIE to be a success, like any project, there needs to be someone on the inside driving it.
You need an apostle. You’ve got to have somebody in the C-Suite or the ED director who’s going to take ownership, to say, “This is a priority everywhere in our state and it’s going to happen in my hospital. It’s going to happen this week. Just got do it. Put other stuff aside and do it.” The way we did that in Washington state was through [Washington state ACEP’s] ED Directors Forum. We just said, “Here’s this year’s top priority, everybody. Let’s go and get it working.”
Stay tuned for Part 2 of our interview in coming days, where Dr. Anderson shares the six “versions” of EDIE.
Stephen H. Anderson, M.D., F.A.C.E.P., has practiced for nearly 30 years at MultiCare Auburn Medical Center in Auburn, Mich., holding positions including Chairman of Emergency Services, Stroke Care, Trauma Care, Education, and Chief-of-Staff. Over the last few years as President of the Washington Chapter of ACEP, Dr. Anderson fought flawed public policies surrounding restricting access to care for State Medicaid patients, and Mental Health Boarding in ED’s. He is a co-author of Washington state’s “Seven Best Practices,” a program many states now use as a blueprint to increase patient access, coordinate care of high utilizers, save lives and save states Medicaid costs. In 2014, he was elected to the National Board of Directors of the American College of Emergency Physicians, advancing the practice of its 37,000 members. He serves as secretary, treasurer & Chairman-Elect of the Emergency Medicine Foundation.