A recent article published in the PM& R journal discussed ways in which two communities used an alert system to help target and address gaps in population health management. The authors noted that pivotal actions for reducing hospital readmissions and avoidable emergency department visits include communication that is more timely and focused, along with better chronic disease management using health technology. One tool being used by some health systems is an electronic alert system that notifies the provider or site daily about a patient’s ED visit or hospital admission. Through these alert systems health care organizations can better coordinate care to help identify high and frequent utilizers and those patients that might benefit from increased intervention.
Current alert systems have three main steps:
- Visit to the ED or hospital admission triggers an Admission (A), Discharge (D), Transfer (T) message;
- Patient information is matched to participating site patient list and a secure messaging system sends an electronic alert; and
- The participating site receives the electronic alert
In addition, on a daily basis, participating sites receive a list of the patient alerts in a secure email message and can work on stratifying patient risk and conduct follow-up as needed. Healthcare facilities using the alert system have integrated:
- Pharmacists to follow up on medication changes and additions or if a patient has a complicated medication list;
- Behavioral and substance abuse centers to provide follow up or discharge planning help by a case manager;
- Academic student health clinics to follow up on high-risk patients, ensure specialist referrals are made and education about available services;
- Follow up by community health workers or a Care Coordinator for the uninsured, underinsured and vulnerable populations and/or
- Monitoring chronic pain and pain medication management for potential abuse.
Adopting an electronic alert system may help to provide healthcare facilities with
- Quicker and more appropriate engagement with high utilizers of the health care system
- Method to identify target populations and the ability to risk stratify patients
- Ability to track and measure outcomes and evaluate the effectiveness of interventions
- Increased care coordination among providers and specialists
- Facilitation of cost savings
The use of the HealthLINC technology was tested in two communities in Indiana and South Carolina. The main goal of this technology is to enhance communication between hospitals and providers. Although Indiana and South Carolina sites have begun to successfully use this technology, it is no stranger to Michigan hospitals. Since 2010, The Michigan Health Information Network (MiHIN) Shared Services has helped provide a variety of technological services and opportunities for hospitals, one being ADT message software. MiHIN strives to accomplish its goal of improving healthcare experiences by supporting the statewide exchange of health information data among appropriate stakeholders. To meet its mission, MiHIN partners with a variety of Michigan Health Information Exchanges (HIEs) such as PatientPing, Southeast Michigan Health Information Exchange (SEMHIE), Upper Peninsula Health Information Exchange (UPHIE) and many others, to help disseminate real-time ADT messages. This service can be very valuable in better understanding the many pieces involved in a patient’s care story.