Doctors tell insurance companies about the care patients receive; one of the countrys largest emergency departments is finding that, with the right IT, insurance companies can return the favor.
Patients seeing a doctor for the first time often omit important details. The situation is worse, and more dangerous, when these patients show up in emergency rooms.
Doctors treating trauma patients should know, for example, whether someone is taking blood thinners. Medications like Viagra can cause chest pains and raise the risk for heart attack in some patients, but patients often dont mention their use of the drug. Knowing that a patient recently filled a prescription with potential psychological side effects also helps clinicians decide what care and counseling is necessary.
Even when patients are lucid, clinicians often have no way of knowing such information, but insurance companies have a record of every bill, or claim, theyve paid for medical procedures and medication. At Christiana Care Health Systems, based in Newark, Del., technology vendor MEDecision and Blue Cross Blue Shield Association, the regions dominant health insurance plan, teamed up to help that information get to physicians.
“The process is around taking claims data—which is not terribly accessible from a clinical point of view—and turning it into something that a doctor or nurse could use to make decisions,” said Edward Ewen, a physician and director of clinical informatics at Christiana Hospital.
“Theres no question: More complete information means better decisions,” Ewen said.
When emergency patients are registered, administrative staff go to a Web site and print out clinical summaries based on information stored by Blue Cross Blue Shield. Nurses use the summaries to triage patients and to guide patient interviews, and the information is then given to doctors.
But turning claims data into information doctors can use is easier said than done, said John Capobianco, president of MEDecision. Just because a doctor ordered a test for Lyme disease or diabetes doesnt mean the patient has that condition. Instead of just accumulating claims, MEDecision analyzes insurance data to create a clinical summary of a patients likely conditions and current medications.
Still, doctors and nurses must be alert for misleading information. “We had to make real clear to our staff that they still need to use their heads and their interviewing skills,” Ewen said.
Nonetheless, its clear that clinicians find the summaries valuable. “Its become such a part of their standard workflow that they just assume its going to be there,” Ewan said. “When I told them that it was a pilot that might go away, the head nurse was very upset.”
Right now, Blue Cross Blue Shield pays for Christiana Health System to have access to the clinical summaries, Ewen said. BCBS is also in charge of obtaining patient consent.
The program is still being studied for cost savings and efficacy, but Ewen said an informal study shows that the claims data provides information that Christiana staff did not have about 40 percent of the time. Claims data omits many details clinicians find useful, like information about patients living conditions, but its still better than nothing.
For Ewen, he said, the most frustrating aspect of the pilot program is that doctors can only get information for Blue Cross Blue Shield patients, and even then, only for health groups that are part of the program. Thats about 20 to 30 percent of patients. And if a patient leaves that insurance plan, doctors can no longer access that record.
Not surprisingly, MEDecisions Capobianco said he sees an emergency room accessing data from a single insurance company as just a start. In the summer of 2006, Blue Cross and Blue Shield of Illinois, the largest commercial health insurer in the state, will start providing data to doctors and hospitals across the state. But Capobianco said he imagines a system in which both providers and payors could feed information into an RHIO (Regional Health Information Organization) that could, with patient input, then give relevant information to clinicians that need it.
Capobianco said he thinks health care payers, like Medicare and insurance plans, should be the first to step up to share information. If health care providers plug in first, early adopters wont see much benefit, he admitted. “If a regionally dominant payer joined first, what would happen? On Day 1, the first provider has a 60 percent chance of getting information about patients.”