This quality improvement project aimed to enhance clinical data sharing between an emergency department and community health center treating homeless patients. An assessment found the organizations currently shared some electronic health data but the health center lacked access to patient summary data from the hospital. A clinical data integration plan was then developed to modify their electronic medical record systems and improve access to accurate medical information across sites of care for homeless individuals.

1. A Plan for Multiagency Health Care Data Sharing in Homeless Care Gwendolyn S. Williams, DNP Student The University of Alabama Capstone College of Nursing Summer 2011

2. Abstract This multiphase process quality improvement project was designed to improve clinical data sharing systems used by an emergency department and a community health center that treats and refers homeless patients between them.

3. Abstract This multiphase quality improvement project was designed to enhance clinical data sharing systems used by an emergency department and a community health center that treats and refers homeless patients between them. Data obtained from a variety of assessment sources supported the need for improving communication between these two organizations in the care of homeless individuals in a southeastern community in the U.S. Subsequently, a clinical information data sharing plan was developed to enhance the clinician’s ability to access accurate medical information wherever the patient seeks care.

4. Introduction Health care for homeless individuals can be a complex endeavor for communities. The common transitory characteristics of this population compromised by myriad health care complexities require the combined involvement of multiple institutions in the care of each patient. Often the burden of providing that care rest with non-profit public agencies. This burden includes financial cost but also consist of unique problems associated with coordination of care (Savage et al., 2006). For example, usually when homeless individuals seek care from a health facility, they have no medical records due to inconsistent medical treatment (Cavacuiti & Svoboda, 2008). There is a need for accurate, complete health information to be available to clinicians at the point of service when providing care to patients (Buck, Rochon & Turley, 2005). The use of information technology makes it easier to manage complex disease processes as often seen in homeless individuals (Cavacuiti & Svoboda, 2008). At present the internet and various interface software engines can link patient data from multiple institutions enabling immediate decision making.

5. Purpose The purpose of this project was to enhance clinical data sharing between an ED and CHC to ultimately improve service access for homeless persons in this community. Specifically, the project sought to facilitate the flow of accurate information at the point of care using multiphase process oriented quality improvement methods.

6. Methods Phase I Assessment The first phase involved assessment and included academic research of the topic. With the assistance of library staff from the University of Alabama and an information specialist, a literature search was performed of PubMed and Medline using MeSH terms and keywords including homeless health care needs, integrated clinical delivery systems, multi-disciplinary care coordination, and electronic medical records.

7. Design This is a multiphase process oriented quality improvement project. This project has four phases: Assessment- existing clinical data sharing procedures between the organizations Planning- develop plans to enhance current data sharing systems Implementation- guided by the new data sharing model Evaluation- include process and outcomes measures

8. Assessment Data Collection The assessment of existing tracking and referral, discharge planning, and clinical information exchange between the two organizations was performed using a variety of sources including a questionnaire. A list of essential questions and their underlying rationale was generated from findings in the literature. In addition, the questionnaire design of Cavacuiti and Svoboda (2008) was utilized as a primary framework in choosing appropriate questions for conducting interviews. With the assistance of each organization, individuals identified by the managers as most knowledgeable about existing referral processes and health information sharing for homeless patients were interviewed using the questionnaire.

9. Assessment Data Analysis The response to each question was recorded by the author. The recorded notes were written in narrative format. To improve the display of data the questionnaire was formatted in tabular design. The organization’s responses to each question was summarized in the response tab.

10. Assessment Findings Assessment responses revealed that the two organizations were currently sharing electronic health data through the hospital’s MEDITECH system. Presently, the CHC is only allowed access to their patient’s outpatient laboratory and diagnostics via the MEDITECH system. To support further clinical data sharing, the CHC needs access to patient’s summary data from the hospital’s MEDITECH system for referrals shared between the organizations.

11. Interview Questionnaire QUESTION 1. How many homeless are seen in a month? 2. What are common services you provide to homeless? 3. What are patient outcomes of common services provided by your organization? 4. What common health problems do you see in homeless? 5. What are the demographics of homeless seen? RESPONSE The CHC does not have a system for tracking this data; an estimate of approximately 25 referrals of homeless per week with a total number of 300 frequent system wide users was given. The ED does not have a system for tracking this data. The CHC provides medical, case management, psychosocial assessments, transportation, and dental services. The ED does not track this information. Neither organization tracks this information. The CHC sees patients with hypertension, diabetes, skin disorders, respiratory issues, depression, substance abuse, and vaginal disorders. The ED does not track this information. The CHC predominately treats Caucasian males between the ages of early 20s to middle 50s and a small number of single mothers from a local shelter. The ED does not track this information.

12. Interview Questionnaire The CHC reported that homeless primarily reside in Tuscaloosa in shelters, double with relatives, or foster care, while a small number transition from surrounding cities and states. The ED does not track this information. The CHC uses the NEXGEN EMR system; however, implementation has not occurred at the health care for homeless (HCH) program location. The ED utilizes the emergency department management (EDM) module within the MEDITECH EMR system. The CHC system has this capability when fully implemented. The ED MEDITECH system has this capability pending granting of access. Standard clinical data for example, patient demographics, medical and social histories, etc. are collected by each organization. The CHC’s NEXGEN system is secure web based, enabling clinical data exchange between departments and with other organizations. The ED’s MEDITECH system is proprietary, it can only be modified by the software vendor and is not available free of choice. Consent forms are used by both organizations. Both organizations have referral and interagency agreements regarding shared patient referrals. The CHC’s HCH program has service requirement policies that address patients without ID. The ED staff utilizes visual ID of frequent users and data matching components in its EMR. What are the migration patterns of homeless seen? Does your organization use EMRs? Are the EMRs used by multiple disciplines at multiple sites? What data does the EMR collect? Is the EMR open source or web based? How do you insure privacy of EMR information? How is consent obtained to share EMR data between organizations? How does the EMR track individuals without identification (ID)?

13. Phase II Planning During the planning phase a clinical data integration plan was prepared modifying the MEDITECH system to allow the sharing of specific health care data between the two institutions. Phase I and II were the focus of the author’s work.

14. Clinical Health Data Integration Plan

15. Conclusions The planning and development of large quality improvement processes like clinical data integration systems is a unique opportunity for advanced practice nurses to leverage existing HIT investments through cost savings, enhance work flow processes, and increase organizational efficiency and patient specific data accessibility (Sensmeier, 2008). The resulting positive outcomes may provide nurses with useful benchmarking information for planning future process improvement initiatives.

16. References Buck, D. S., Rochon, D., & Turley, J. P. (2005). Taking it to the streets: Recording medical outreach data on personal digital assistants. Computers, Informatics, Nursing : CIN, 23(5), 250-255. Cavacuiti, C., & Svoboda, T. (2008). The use of electronic medical records for homeless outreach. Journal of Health Care for the Poor and Underserved, 19(4), 1270-1281. Savage, C. L., Lindsell, C. J., Gillespie, G. L., Dempsey, A., Lee, R. J., & Corbin, A. (2006). Health care needs of homeless adults at a nurse-managed clinic. Journal of Community Health Nursing, 23(4), 225-234. doi:10.1207/s15327655jchn2304_3 Sensmeier, J. (2008). Deep impact: Informatics and nursing practice. IT Solutions, September, 2-6.