Last week we introduced Larry, the patient with diabetes and a history of non-compliance who is discharged from his local emergency department, but his primary care doctor is never notified about his visit. Larry landed back in the emergency department less than a month later due to complications of his diabetes.

ADT Messages as a Cornerstone of Exchange

Health information exchange (HIE) isn’t easy. Across the country, folks in every state—from CIOs of hospitals, to state agencies, ONC grantees, providers in rural clinics, mobile app developers, EHR vendors, and consumers—are trying to figure out how to make information flow in order to improve patient care (and lower health care costs while we’re at it).

To meet this challenge, everyone must think creatively and use every tool that we have in our toolboxes to enable secure and meaningful exchange. One of those (perhaps surprisingly basic) tools is Health Level Seven (HL7) Admission, Discharge, and Transfer (ADT) messages.

ADT messages are reemerging as the go-to data source for care coordination efforts across states. Ubiquitous in hospital information systems, hospitals exchange thousands of ADT messages (both internally and externally) every single day. These messages communicate that

• a patient’s “state” (admitted, discharged, or transferred) has changed, or
• his or her personal or demographic information (such as the patient’s name, insurance, next of kin, attending doctor, etc) has been updated.

These seemingly simple and ever-present messages contain a wealth of information, and are invaluable tools to help health care providers better coordinate a patient’s care.

How is the Chesapeake Regional Information System for Our Patients (CRISP) Using ADT Messages?

With electronic connections to all 46 hospitals in the state, Maryland’s state-designated entity for health information exchange (HIE), the Chesapeake Regional Information System for Our Patients (CRISP), is harnessing this basic data from ADT messages to help providers better coordinate patient care. We recently caught up with Scott Afzal, CRISP’s Director of Statewide Health Information Exchange, to learn more about what they are calling the Enterprise Notification and Reporting Services.

“CRISP understands the financial and clinical value of information that is as simple as hospital utilization data and that it can have a major impact on the coordination of patient care. Based on our relationship with the hospitals in the state and the type of information and infrastructure we have in place, we realized that we could provide a real-time service that would allow primary care providers and care coordinators to better track their patients, resulting in healthier people and a reduced rate of costly hospital readmissions.”

– Scott Afzal, Program Director of Statewide Health Information Exchange, CRISP

Real-time Electronic Notification Services

Launched last August, CRISP’s Encounter Notification System (ENS) provides real-time electronic notifications when patients are admitted to, discharged from, or transferred within a hospital. For a patient like Larry, the ENS uses ADT messages to help make sure that his primary care providers and care coordinators are notified about his health care encounters like hospitalizations or emergency department visits, which they might not otherwise be aware of.

This tool enables family doctors/internists/geriatricians and their counterparts in the hospital to:

• coordinate his care and help him follow his discharge instructions,
• understand his care plans, and
• receive follow-up care with his primary care provider.

CRISP works closely with providers to set up these encounter notifications:

1. Physicians and care coordinators hand select the patients they have a treatment relationship with and about whom they want to receive alerts.
2. Physicians and care coordinators submit that list of patients (or “patient panel”) to CRISP.
3. CRISP loads the patient panels into their ENS, generating a subscription list for each physician or care coordinator.

Once this process is complete, any time CRISP receives ADT messages for patients on a patient panel, physicians and care coordinators automatically receive an electronic notification.  Recipients can receive notifications as PDFs in electronic inboxes (like secure email), or merged directly into their EHRs as HL7 messages. CRISP uses the Direct Project protocol to securely transport the notifications. The ENS currently has approximately 500,000 unique patients in its notification panels, and sends roughly 600 alerts a day to over 500 physicians and care coordinators.

ADT Messages Also Provide Data for Geospatial Mapping

CRISP is also putting the same ADT messages to work to help Maryland get a more complete picture of hospital system utilization across the state, which will help state policy makers and researchers better understand pressure points in the health care system and target interventions to address them.

CRISP recently began using a new tool to display how patients are using the state’s health care system through geospatial analysis and specific information in the ADT messages (such as facility address). The state is using analyses from a proprietary geospatial tool—called the Geographic Information System (GIS)—to get a state-level perspective of hospital utilization and, more importantly, a view of systemic patterns down to specific city blocks. This allows teams to identify disproportionately high levels of utilization and associated factors that might be at play in a given area. To accomplish this, copies of real-time ADT messages are sent to CRISP’s custom-built database, called the Encounter Reporting Service (ERS), where data from ADT messages can be extracted for various time periods and processed through scripting logic to produce consolidated reports that contain information about:

• inpatient encounters,
• 72-hour emergency department “bounce backs,” or
• 30-day hospital readmissions.

In conjunction with the appropriate policy development, CRISP plans to expand the use of this important tool to enable near real-time visualization of hospital utilization.

Reducing Health Disparities Through Analysis of ADT Messages

Some of the State’s first users of the GIS are Maryland’s Health Enterprise Zones (HEZs), created by the State’s Health Improvement and Disparities Reduction Act to reduce health disparities across Maryland’s racial and ethnic groups and within specific geographic areas. The HEZs are using the tool to improve access to health care while simultaneously reducing health care costs.  The ongoing analysis will be an important tool as they work to gain insight into the current health status and health care patterns within communities. With this new tool, they can better track the care of patients like Larry, and the care his neighbors might or might not be receiving across the health care system.

Big Impact with the Basics

CRISP’s notification and reporting services grew out of a basic, common message type. The simplicity of ADT messages can sometimes mask their importance to coordination of care efforts.  CRISP has demonstrated how this basic building block of health information exchange holds the potential to provide big value for providers and patients.

One of those patients, of course, is Larry. If Larry lives in a Baltimore neighborhood with disproportionately high hospital utilization rates—patients often referred to as “frequent fliers” or “bounce backs”—the information gained through the ERS GIS analysis will help his community design and implement targeted interventions to get him the care he needs, keep him healthy and out of the hospital.

If You Would Like to Learn More

If you are implementing health information exchange services and would like to learn more about how Maryland’s use of ADT messages can inform your own care coordination efforts, visit the State HIE Bright Spots synthesis on care coordination at http://statehieresources.org/bright-spots/ or the CRISP website at http://crisphealth.org/.

If you have any questions or comments about how simple tools like ADT messages can improve coordination of patient care, please leave them in the comments section below.