Emergency Medicine Informatics
Christine Carr, M.D., CPE
Steven Saef, M.D., MSCR
The Informatics Section of the Department of Emergency Medicine is focused on the implementation, evaluation, and expansion of Health Information Exchange (HIE) in our region and state. Drs. Steven Saef and Christine Carr lead these efforts.
In 2008, the four major hospital systems (MUSC, Roper St. Francis, Trident, and East Cooper) serving greater Charleston, SC banded together to create an HIE, the Carolina eHealth Alliance (CeHA). Their goals in this effort were high: to address the problem of fragmented care, safely reduce duplicative testing, decrease ED lengths of stay (LOS), avoid preventable hospital admissions, and improve quality of care. CeHA was founded with a $2.8M grant from The Duke Endowment and enabled, for the first time ever, emergency physicians practicing in 11 EDs within the Charleston area to access patient data from all four competing hospital systems at the point of care. In early studies we demonstrated reductions in duplicative testing, admissions, and consults in 35 percent of these patients, resulting in an estimated cost avoidance of $1.4 million in 1 year across the ED’s in our region (based on a utilization rate of only 2.3 percent.). Preliminary data also revealed a 45 percent reduction in ED LOS for discharged ED patients and a 25 percent reduction in the ED LOS for admitted patients. The combined impact of decreasing avoidable ED testing and decreasing ED LOS provided a much-needed increase in ED capacity at little or no added cost.
Our innovative work on CeHA earned first place in the 2010 Modern Health care Case Study contest sponsored by Modern Health care Magazine. In 2014, we were the invited keynote speaker at the Pennsylvania e-Health Collaborative to speak on HIE. Our research in the DoEM has been highlighted in multiple IT publications, and we have been invited to speak around the country about the success and results of our research.
Drs. Saef and Carr lead a multidisciplinary research team including medical students, residents, health economists, statisticians, informaticists, and emergency physicians, and have published 7 peer-reviewed studies on the impact of HIE on quality, efficiency, user adoption barriers and care coordination. Saef and Carr are Co-Investigator’s on the team that won a second Duke Endowment grant ($600K) to expand the capacity of CeHA. Subsequent grant funded work has been presented at ACEP and/or SAEM national meetings every year for the past 6 years. We are committed to education and have had dedicated students and/or residents on almost every publication and they have presented at several of our national meetings.
Recently we have partnered with our colleagues in the MUSC BioMedical Informatics Center (BMIC) and have submitted several grants that focus on using data from CeHA in an effort to improve health by using predictive analytics to identify patients at risk for abuse, patients that didn’t get follow up or patients that had a missed opportunity in the ED.
In April 2016 as Co-PI, Dr. Carr was awarded a $25K CTSA Carolinas Collaborative grant (with Co-PI’s and Informaticists at UNC, Wake Forrest and Duke) “The HEART Pathway: a learning health system project, translating evidence into practice across the Carolinas”. This grant will be used to investigate the impact of informatics on ACS rates and Health care utilization by ED patients with acute chest pain across multiple health systems. The goal of the study is to develop informatics tools which can facilitate efficient, evidence-based interventions across the multiple hospitals in the Carolinas Collaborative. The HEART pathway uses a validated clinical decision aid and serial troponin measures to provide real-time decision support to providers. In prior studies, the HEART Pathway decreased hospitalizations, stress testing, and hospital length of stay, without increasing adverse events. These studies led to a learning health system project in collaboration with insurers, in which the HEART Pathway was fully integrated into the Wake Forrest Baptist Hospital EHR. Preliminary results from WFBH demonstrate further reductions in hospitalizations and stress testing.
We are proud to say that almost every CeHA publication has included a junior faculty member, resident or medical student. Dr. Saef leads several Medical Student Research electives that allow the students to participate in research design, evaluation, presentation, and publication of our work. Many of these presentations have been nationally recognized.
Dr. Carr supervises 3 to 4 Masters students/semester for the Division of Health Informatics in the College of Health Professions and she is a Capstone Leader for the MUSC Masters in Health Informatics program. These Masters students study and analyze the various proposed HIE Use Cases described above, as well as examine the architecture and design elements of HIE in our community.
We are pursuing opportunities with DHEC and Health Sciences South Carolina (HSSC) to secure funding to expand the Use Cases of CeHA to include Disaster Reunification, Capacity Management, Care Coordination/access to Advanced Directives and an EMS Pre-Hospital Access to Care project. This The DHEC reunification project has been funded and is hoped to begin in the summer of 2017. We hope to study how improved coordination with HIE can improve health in the rural areas of our state. We envision linking HIE with TeleMed technology as a way to create an “immediate continuity of care document” and create less fragmented TeleHealth Care. We have had initial talks with Williamsburg Regional Hospital, a 22 bed critical access hospital, about establishing a link to our HIE. This would create an HIE enabled “single health record” that could identify gaps in care, allowing these to be remedied at any point-of-care (school, work or physician office). This work is key to improving care coordination and reducing the fragmentation of Health care for this very underserved community.
The aim of our section is to use science and investigation to demonstrate the benefits of sharing health information across disparate systems as we move toward a national health information network (NHIN). Many challenges remain in the path to obtaining the cooperation necessary from major stakeholders in the Health care industry to accomplish this. We believe the studies we have completed barely scratch the surface of what can be accomplished; potential applications of HIE are in many ways limited only by imagination. We are anxious to collaborate with other investigators who are looking for ways in which HIE can be used to improve our patients’ lives and repair the Health care system in the United States.
Saef SH, Carr CM, Bush JS, Bartman MT, Sendor AB*, Zhao W, Su Z; Zhang J, Arnaud C, Marsden J, Melvin CL, Lenert L, Moran W, Mauldin P, Ph.D.; Obeid J. A comprehensive view of frequent Emergency Department users based on data from a regional HIE. South Med J. 2016 Jul;109(7):434 to 9. PMID: 27364030 **
Melvin CL, Saef SH, Pierce HO, Obeid JS, Carr CM. Health Information Exchange in the Emergency Department: What Do Emergency Department Clinicians Think? South Med J. 2016 Jul;109(7):419 to 26. PMID: 27364028 **
Carr CM, Saef SH, Zhang J, Su Z, Melvin C, Obeid JS, Zhao W, Arnaud CL, Marsden J, Sendor AB*, Lenert L, Moran WP, Mauldin PD. When should ED Physicians use an HIE? Predicting presence of patient data in a HIE. South Med J. 2016 Jul;109(7):427 to 33 PMID: 27364029 **
Saef SH, Melvin CL, Carr CM. Impact of a Health Information Exchange on Resource Use and Medicare-Allowable Reimbursements at 11 Emergency Departments in a Midsized City, West J Emerg Med. 2014 Nov;15(7):777 to 85 PMID: 25493118 **
Carr CM, Gilman CS; Krywko DM, Moore, HE*, Walker BJ, Saef SH. Observational Study and Estimate of Cost Savings from use of a Health Information Exchange in an Academic ED. J Emerg Med. 2014 Feb;46(2):250 to 6. PMID: 24071033
Carr CM, DiGioia C, Wagner J, Saef SH. Primer in Health Information Exchange for the Emergency Physician: Benefits and Barriers. A Clinicians Perspective. South Med J. 2013 Jun;106(6):374 to 8. PMID: 23736180
Carr CM. Coordinating Care, Lowering Costs, Improving Quality, and Efficiency for Patients Who Receive Care in Both Academic Medical Centers and Community Hospital Settings. AAMC MedEd Portal. Oct 2012
Saef SH, Carr CM, Bush JS, Bartman M, Sendor AB*, Spearman JB*, Zhao W, Su Z, Zhang J, Arnaud C, Marsden, J, Lenert, L, Moran, W, Mauldin, P, Obeid J. Can Data From a Health Information Exchange Be Used to Describe Frequent Emergency Department Users Within a Region? Ann EM, V66, 4S, Abstract No. 248, pp89 to 90. doi:10.1016/j.annemergmed.2015.07.281 October, 2015
Sendor AB*, Obeid J, Zhang J, Arnaud C, Marsden J, Melvin CL, Saef SH, Carr CM. A Comprehensive View of Frequent Emergency Department Users Based on Data From a Regional HIE. Presented at the 50th Annual Perry V. Halushka MUSC Research Day, Charleston, SC, November 12 to 13, 2015. Abstract published in the accompanying syllabus: http://academicdepartments.musc.edu/grad/students/curr_students/research_day/2015 percent20Research percent20Day percent20Booklet.pdf (PDF).
Carr CM, Saef SH, Zhang J, Arnaud C, Marsden J, Melvin CL, Moran WP, Mauldin PD. Can Data From A Health Information Exchange Be Used To Describe Patients Who Visit Multiple Emergency Departments Within A Region? May 2014. Acad Emer Med, Vol. 21, No. 5, Suppl. 1, AEMJ , p137. http://dx.doi.org/10.1016/j.annemergmed.2015.07.281 May 2014
Saef S, Bourne C, Bush J, Scott L, Gaafary C*, Walters J, Keenan K, Walker B, Kriza K, Carr C. The Impact Of a Health Information Exchange on Resource Use and Medicare-Allowable Charges at Eleven Emergency Departments in a Midsized Southeastern City: An Observational Study using Clinician Estimates, Medical University of South Carolina, Department of Medicine’s 8th Annual Research Symposium, February 18th, 2014
Saef SH, Hanley M, Zhao W, Walker BJ, Carr CM. Potential to Reduce Lifetime Attributable Risk of Cancer through Avoidance of Radiographic Imaging in the Emergency Department by using a Health Information Exchange: An Observational Study Based on Emergency Department Clinician Perceptions. Ann of EM, Vol. 64, Issue 4, pgS57 http://dx.doi.org/10.1016/j.annemergmed.2014.07.183 Oct 14
Carr CM, Saef SH, Zhang J, Arnaud C, Marsden J, Melvin CL, Moran WP, Mauldin PD. Patients Who Visit Emergency Departments Belonging to Different Hospital Systems are More Likely to Receive Multiple Computed Tomography Scans than Those Who Visit the Emergency Departments of a Single Hospital System. Ann of EM, Vol. 64, Issue 4, pg S85. http://dx.doi.org/10.1016/j.annemergmed.2014.07.266, October, 2014.
Saef SH, Bourne CL, Bush JS, Scott LA, Gaafary HC, Keenan K, Walters J, Kriza K, Walker BJ, Carr CM. The Impact of a Health Information Exchange on Resource Use and Medicare-Allowable Charges at Eleven Emergency Departments Operated by Four Major Hospital Systems in a Midsized Southeastern City: An Observational Study using Clinician Estimates. Ann of EM, V.62, No. 4S, pS97. Oct. 2013.
Carr CM, Krywko DM, Moore HE*, Saef SH, The Impact of a Health Information Exchange on the Management of Patients in an Urban Academic Emergency Department: An Observational Study and Cost Analysis, Ann of EM, Volume 60, Issue 4S, Page S15. DOI: http://dx.doi.org/10.1016/j.annemergmed.2012.06.062. Oct. 2012.
Carr CM, Krywko DM, Saef SH. The Impact of a Health Information Exchange on the Management of Patients in an Urban Academic Emergency Department: An Observational Study and Cost-Benefit Analysis, MUSC Department of Medicine 6th Annual Research Day, Poster #80, Jan 2012.