This HIMSS15 presentation discusses the challenges faced in hospital emergency departments and offers insights for implementing a process to follow up with discharged ED patients to enhance outcomes and satisfaction,while optimizing utilization and reducing risk.
10. CAHPS-Style Surveys
• Most useful for
internal
benchmarking
o By service line
o Year-to-year
• Less useful for
external
benchmarking
(control of variables)
o Against peers
Emergency Department Patient Satisfaction,
Cedars-Sinai Medical Center, http://cedars-
sinai.edu/Patients/Quality-Measures/Patient-
Satisfaction/Emergency-Department-Patient-
Satisfaction.aspx (accessed 2/20/15).
11. Challenges with CAHPS-Style Surveys
• Small Sample Size – typical response rate < 2%1
• Ethno-Demographic Bias – e.g., English speakers
provide higher scores1
• Impact of Outliers – behavioral health and drug-
seeking patients can skew results2
12. Challenges with CAHPS-Style Surveys
• Delay in Acquiring Data
o Survey data is typically not available for a month
or more until after a patient’s ED visit.
• Nature of Emergency Medicine
o Time spent with acute patients may detract from
time with less acute patients.
o Acute patients are frequently admitted and thus
their satisfaction scores may not be tied back to
the ED.
Sullivan W and DeLucia J. 2+2=7? Seven things you may not know about Press Ganey Statistics.
Emergency Physicians Monthly. September 22, 2010. www.epmonthly.com/features/current-features/227-
seven-things-you-may-not-know-about-press-gainey-statistics/ (accessed 2/20/15).
14. Objectives for an ED Follow-up System
• Efficiently assess patient wellbeing on the day after
discharge1
• Alert providers to gaps in post-discharge knowledge
(instructions, medications) or access to follow-up care1
• Document patient satisfaction with providers and with
the overall ED experience1
• Provide specific patient experiences to review in the
daily huddle in the Emergency Department2
1
Scaletta T. Automating Patient Contact After ED Discharge Enhances Safety and Reduces Risk.
Storyboard presented at the 26th Annual National Forum on Quality Improvement in Health Care.
December 7-10, 2014, Orlando, Florida.
2
Steenbergen P. Incorporating “Medical Minute” Into Daily Huddles in the Emergency Department. Studer
Group. June 11, 2014. www.studergroup.com/resources/news-media/publications/insights/june-
2014/incorporating-medical-minute%E2%80%9D-into-daily-huddles-i (accessed 2/20/15).
15. Evaluating Wellbeing
• The most critical component
of follow-up
• Extends care outside the
walls of the ED
• Can parallel processes
already in place to address
serious post-discharge
issues (such as positive
microbiology cultures)
CVVV
16. CVVV
Identifying Gaps in
Understanding
• Areas to assess:
o Discharge
instructions
o New medications
o Follow-up
appointments
• Essential to have
processes in place to
address a knowledge gap
or need for timely
assistance
17. CVVV
Rating the Providers
• When sample sizes and
response rates are large,
provider ratings become
statistically valid and more
compelling
• Systems should match
patient feedback to specific
providers
• Best approaches can
eliminate responses from
drug-seeking, behavioral
health and other care plan
patients
18. CVVV
Rating the Providers
• Nurses, residents, mid-levels,
and other staff may be rated
• Rapid feedback can be
leveraged to modify behavior
• The best approaches also
report work efficiency and
utilization metrics by provider
19. CVVV
Evaluating Other Aspects
of the Care Experience
• Open-ended questions are
useful for uncovering
opportunities to enhance
patient experience
• Forward-thinking
organizations may vary
survey questions from time to
time to evaluate the impact of
specific patient experience
initiatives
24. EHR-Embedded Call Manager
• During the ED visit, the provider selects in the EHR
whether the patient is to receive a call back and by
whom (attending, specific mid-level or mid-level pool)
• EHR sends email alert to an appropriate provider’s
“Call-Back Folder” (queue)
• Provider initiates telephone encounter via link in email
• Navigation template facilitates documentation of patient
responses to survey questions within the EHR
• Full business rules and logic including ability to quickly
generate a new prescription
28. Hybrid Approaches
• A combination of any of these approaches:
• In-house survey
• Call-back
• IVR
• Email
• Text (SMS messaging)
• Multiple methodologies may increase overall response
rates
• Effective systems attempt one approach and then “roll”
to the next approach
29. Hybrid Approaches
Daily Data Upload
from the EHR
Secure, HITRUST-Certified,
HIPAA-Compliant Cloud-
Based ServerEmergency Care
Innovation of the Year
Awards
Structured Electronic Follow-Up for
Patients Discharged from the ED
Edward-Elmhurst Healthcare
Urgent Matters Names Winners of the 2014
Emergency Care Innovation of the Year Award,
George Washington School of Medicine &
Health Sciences,
smhs.gwu.edu/urgentmatters/news/urgent-
matters-names-winners-2014-emergency-care-
innovation-year-award (accessed 2/20/15).
First Layer
Text / Email
Contact with Patient
Second Layer
Call Center Contact
with Patient
Patient
Monthly Performance
Reports
Case Manager
Addresses any
Outpatient
Management Issues
34. Frequent ED Users
• High ED Users (≥4 visits/2 years) comprise 1 percent of the
population and 16 percent of ED expenditures1
• 14 to 27 percent of all ED visits could take place at alternative
sites saving $4.4 billion annually2
• A multidisciplinary ED-care-coordination program was found to
reduce ED visits by 79 percent for extreme ED users (>12 visits/
year) and 71 percent for frequent ED users (3-11 visits/year)3
o Direct costs were reduced by $24,364 and $5,140 per year
for the extreme and frequent users, respectively
1
Kaiser Family Foundation. Characteristics of Frequent Emergency Department Users. October
2007. www.kaiserfamilyfoundation.files.wordpress.com/2013/01/7696.pdf (accessed 2/20/15).
2
Weinick RM, Burns RM, Mehrotra A. Many emergency department visits could be managed at urgent care centers
and retail clinics. Health Aff (Millwood). 2010;29(9):1630-6.
3
Murphy SM, Neven D. Cost-effective: emergency department care coordination with a regional hospital information
system. J Emerg Med. 2014;47(2):223-31.
35. Potential to Reduce Observation Admissions
• Short-Stay Observation Admission
o Challenging for the hospital –
“soft” admission reimbursement is
less than for inpatient admissions
o Challenging for the patient –
Medicare patients are covered
under Part B (higher out-of-pocket
charges and co-pays)
o May adversely impact satisfaction
• Observation admissions may be
reduced with post-discharge wellness
checking
Two-Midnight Rule
Limits hospital discretion
with observation stays that
do not span at least two
midnights.
Treated as outpatient visits
under Medicare Part B.
Kelly T. The observation admission - overcoming challenges for improved patient satisfaction. Becker’s Hospital
Review. November 13, 2014. www.beckershospitalreview.com/hospital-management-administration/the-observation-
admission-overcoming-challenges-for-improved-patient-satisfaction.html (accessed 2/20/15).
43. IHI Triple Aim Satisfaction
• Patients appreciate contact
• Complaints addressed
• Providers held accountable
Better Health
for Populations
Lower
Per
Capita
Costs
Better
Care for
Individuals
Safety
• Recover
from missed
diagnosis
• Resolve
follow-up
issues
Savings
• Improve
loyalty
• Address
frequent
visitors
44. Strategies to Extend Care in the ED :
A Review of Benefits Realized for the
Value of Health IT
http://www.himss.org/ValueSuite
S
T
E
P
S
Increase patient satisfaction as service issues are
addresses and concern for progress is expressed
Enhance the treatment of high-frequency ED
utilizers while optimizing observation admissions
Communicate with patients electronically and
enhance use of the patient portal
Ensure understanding of patient education materials
and compliance with aftercare instructions
Focus clinical personnel on the resolution of patient
issues saving staff for direct patient care