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Health IT Success Stories

Dr. Jonathan Tolentino Improves Care Coordination through Emergency Department Alert System

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Dr. Jonathan Tolentino is an internal medicine and pediatrics physician at the University of Cincinnati (UC) Internal Medicine and Pediatrics practice, a hospital-based clinic in Cincinnati, Ohio. The clinic is part of a safety net system for patients with no insurance; 43% of Dr. Tolentino’s patients are Medicaid beneficiaries. “Our practice is a teaching clinic. We have 6 attending physicians, nearly 30 residents, and several RNs and Medical Assistants,” stated Dr. Tolentino. Electronic health records (EHRs) are one significant part of the practice’s learning environment.

Transitioning to a Health Information Exchange

In 2011, Dr. Tolentino’s practice adopted an EHR system to participate in the Greater Cincinnati Beacon Community Program. As part of the Program, Dr. Tolentino and his colleagues needed to interface with UC Hospital’s health information exchange (HIE). One important part of the HIE was the Emergency Department/Admission Alert System (ED Alert System). The ED Alert System notifies the clinic when one of its patients has an Emergency Department (ED) or hospital admission, then allows the clinic to follow the patient through discharge and ensures the patient has a care plan to prevent future admissions.

Interfacing with the HIE, however, proved to be a difficult task. “One of biggest challenges was transferring data from one system to another,” explained Dr. Tolentino. “It was difficult to adjust to a new system, with the additional patient information from the HIE, and track that information to maintain fidelity.” One way the clinic overcame this challenge was through a shift in workflow. Rather than having the front desk staff receive alerts from the ED Alert System and assign proper follow up, the clinic assigned a medical assistant (MA) to take on this role. The MA not only had more time to troubleshoot data transfer issues, but also had more experience with clinical decision-making. Using the MA facilitated the transition to the new technology and helped the clinic gain interoperability with the hospital’s HIE. “After our patients are discharged from the hospital or ED, our clinic is able to proactively reach out to them to make sure they understand their discharge plan and set up follow-up appointments as needed,” explained Dr. Tolentino. In addition to the post-discharge follow-up, the clinic uses an EHR-based risk stratification model to get a better idea of which patients need the most assistance. “The risk stratification system, combined with the ED alerts, not only helps us deal more aggressively with high-risk patients, but also helps us increase care coordination,” explained Dr. Tolentino.

A Clearer Picture of Patient Needs

The most valuable part of the ED Alert System has been the new information that Dr. Tolentino has learned about his patients and subsequent improvements in care coordination achieved by his clinic. For example, Dr. Tolentino found out that only 20% of his patients with diabetes went to the ED for diabetes-related reasons, however a large proportion of patients visited the ED because that was the only place public transportation brought them. In response, the clinic is working with its social worker, its inpatient discharge coordination team, and other medical staff to help coordinate transportation, home health, and other social needs for its patients, which better enables patients to access primary care instead of going to the ED.

Next Steps

In the coming months, Dr. Tolentino plans to change the EHR’s processes to better detect and flag high-risk patients in need of social supports, such as transportation. The next evolution of the project will use information from the ED Alert System to better coordinate the transition of care for high-risk patients admitted for inpatient hospital stays. This effort is intended to help anticipate patient needs prior to discharge; promote clear communication between outpatient and inpatient providers; and assure that providers meet patients’ social needs and provide access to medications and discharge instructions during the key transition period from inpatient to outpatient care. His organization is also preparing for Stage 2 meaningful use. “Our EHR and the ED Alert System have been great tools to use in our efforts to prevent ED visits among our patients with chronic diseases,” said Dr. Tolentino.