Case Studies

The Institute of Medicine has recently reported that $750 billion dollars is wasted in the health care system on an annual basis. That’s one out of every three dollars spent in the United States on health care.   Members of the Texas e-Health Alliance are committed to implementing technology that improves the health care system for patients.  Part of that mission includes sharing industry expertise and experience with policymakers, and spreading the message that investing in health information technology makes good financial sense.

In that spirit, our organization is pleased to present this set of specific, real-world examples showing how HIT is changing healthcare in a positive way. These case studies have been curated to show how our members are putting the best practices highlighted by the IOM into everyday use.

While this page only provides a high-level overview of each case study, everything listed is an actual implementation, supported by case studies and documentation.    The studies have been divided into categories, with entries addressing each of these topics from the IOM report:

• Using information technology more effectively
• Creating systems to manage complexity
• Making health care safer
• Improving transparency
• Promoting teamwork and communication
• Partnering with patients
• Decreasing waste and inefficiency

More information on each case study is available upon request through our contact page.

Case Study 1.1:  Telemedicine Reduces Psychiatric Hospital Admissions

In rural East Texas, a comprehensive psychiatric emergency service is providing 100% of its psychiatric care via telemedicine.  Within 15 minutes of arrival at the provider site, a patient is assessed by a registered nurse and a licensed counselor or social worker to determine appropriateness for admissions.  The patient is scheduled to see the psychiatrist within 30 minutes via videoconferencing regardless of the hour of day or day of the week.  The psychiatrist is also available by phone within 5 minutes.  These are maximum response times, and the actual response is often much faster.

The rapid psychiatric response allows for quick de-escalation of psychiatric symptoms through use of medications and/or psychological interventions.  In addition, a wide array of medical issues can be treated by the emergency telepsychiatrists, including alcohol and drug detoxification, diabetes care, moderate infections, hypertension, thyroid disease, asthma, nonacute seizure management and other conditions.

Program outcomes include:

• Only 15% of patients needed transfer to a higher level of care compared to 100% before program implementation
• Only 30% of patients in the locked unit needed to be sent to a hospital compared to 100% before program implementation
• Reduction in state hospital utilization in the 12 county region by 32%

By using telemedicine, emergency psychiatrists are always available to this large rural Texas region, and response times are typically shorter than emergency programs with onsite psychiatrists.  Telepsychiatry is a viable solution to many locales around the country that face shortages in psychiatrists.

Case Study 1.2: EHR Tools Increase Tobacco Cessation Referrals

Healthcare providers and delivery systems are ideal intervention sites for conducting the recommended ask-advise-refer tobacco cessation protocol with patients. This protocol has implemented in a project designed to improve healthcare provider referrals to a state-funded quitline. The quitline is an evidence-based tobacco cessation intervention that assists patients ready and willing to quit tobacco.  The project uses electronic health records (EHRs) to assist clinicians with providing tobacco cessation and referral options to patients.

This approach has been integrated into a large healthcare system within the state of Texas. Patients referred to the quitline are proactively contacted and enrolled in free tobacco cessation counseling. Nicotine Replacement Therapy is also available to qualified patients. The project involves an ongoing, collaborative effort with a healthcare system and its EHR vendor to train providers on the proper implementation of an EHR version of the ask-advise-refer method.   Project outcomes, including referrals to quitline, were monitored by the EHR vendor and compared to state-level quitline enrollment reports.

The preliminary findings of the project are showing great results.  Baseline data indicates a total of 7 patients were referred to the quitline service the year before.  Since the project began, more than 80% (230,901) of the patients were screened for tobacco use. Of the group screened, approximately 13% (26,788) were identified as tobacco users and 4.67% (1253) stated they were ready to quit.  The patients who were ready to quit had a referral rate of 85.5% (1075), much increased from the same time period the previous year.

Case Study 3.1 – Health Information Exchange Reduces the Cost of Care

A provider in North Texas was seeing a 64 year old female patient, with primary biliary cirrhosis and concurrent alcohol abuse. She was not compliant with office follow up for two years and presented to the office on 12/2/09 with her daughter manifesting jaundice and confusion consistent with mild hepatic encephalopathy. The patient’s confused mental status prevented a reliable history and the daughter was unaware of medications or pertinent medical history.

A health information exchange (HIE) provided a wealth of clinical information at the time and place of service allowing for a more accurate assessment of the patient’s medical status during the office visit and prevented the expense of duplicate diagnostic and imaging studies. Further, the available laboratory studies available provided a baseline for comparison of subsequent studies. From the medication list it was determined that Doxepin was a likely contributor to the patient’s progressive encephalopathy and it was discontinued.

Costs were reduced or saved as a result of the information being available at the time of visit with her Gastroenterologist. The diagnostic tests that would have been potentially ordered and the costs associated are $15,191 at the Medicare Fee schedule for Tarrant County, Texas in 2010 and the commercial insurance reimbursement (assumed at 140% of Medicare) within the community was $24,086. Since the needed clinical information was available via the HIE these expenses were not incurred.

Case Study 3.2:  Using Claims Data to Supplement Patients’ Clinical Health Information

Providers and their staff rely on information available in the Electronic Medical Record (EMR) System to track and assess the patients’ health and care. Modern EMRs are connected and have the ability to obtain available patients’ health information from other providers. But even with the advancement in Health Information Exchange capabilities, the information available remains somewhat limited. Having access to claims based health information can enhance the information available to providers.

A large state Medicaid program was directed by their legislature to develop a claims based electronic health record system, which is available to Medicaid providers today. Providers can access the information online or download it for offline use or for importing into their own EMRs. The information available in the system is used in parallel to information available in the providers EMRs and offers the following advantages:

• It includes information from all Medicaid providers caring for the patient. It is not limited to specific managed care plan or to the patient data providers may have in their EMRs.
• The claims data can be used to monitor the patients’ compliance with filling their prescribed medications. A paid prescription claim indicates that the medication was filled and picked up.
• Claims can also include important information about the patient outside the specialty of the treating provider such as eye and dental services.

During a pilot program in 2015 the program collected provider’s feedback. One of the providers stated that his staff were able to identify potential drug shopping behavior by reviewing the claims of one their patients. Another provider identified possible abuse of the Medicaid transportation services offered to one of his patients. Program like this can help providers monitor and promote the safety of care provided to patients.

Case Study 3.3: Using Technology to Support End-of-Life Care Decisions

In April 2016, a hospital medical ethics director in North Texas contacted leadership of a company offering digital creation, storage, update and retrieval of emergency, critical and advance care plans (ECACPs) requesting help to understand the history of an ECACP that was presented by a person claiming to be the healthcare agent named in the ECACP for an unresponsive patient. The hospital was somewhat suspicious of the validity of the ECACP and/or the motivations of the self-proclaimed healthcare agent and requested that the technology company audit the history of this particular ECACP. Using a combination of digital information and unique markers in its proprietary system, the technology company was able to confirm that the patient could not have created the ECACP nor appointed the healthcare agent in question. In addition, there were no digital witnesses, no other personal contacts or physicians listed, and no video testimonial by the patient, lending further doubt to the authenticity of the ECACP. The technology company was able to provide all of this information to the hospital leadership – something that would never have been possible with a paper advance medical directive – and the hospital was able to confront the healthcare agent and provide better and safer care to the patient.

Case Study 4.1: Using HIT to Reduce Psychotropic Medication Use

The Health Passport is a patient-centered, Internet-based, health record system that a health plan in the south-central region of the United States began using in early 2008. It makes a foster child’s information available to authorized physicians and other stakeholders involved in the child’s care.  While the data stored in the Passport do not encompass all information included in a complete medical record, it does contain information on patient demographics, physician visits for which claims have been submitted, allergies, lab test results, immunizations and filled prescriptions.

Before this program was implemented, data released by the state demonstrated that foster children were being overprescribed psychotropic medications. Because these children are repeatedly relocated, physicians are frequently unaware of a child’s existing medication regimen and often prescribe another treatment beyond current therapy. The state had established a practice parameter regarding psychotropic medication use for foster children, and the health plan involved was tasked with monitoring the use of psychotropic medications in the foster care population in direct comparison with state parameters.

To date, over 54,000 foster children and their medication prescriptions have been screened or rescreened.   As a result, there has been a 17% reduction in the overall prescribing of psychotropic medications, but more specifically, an almost 50% reduction in the number of children who were prescribed a psychotropic medication for 60 days or more. Even more dramatic have been the 70% reductions in the prescribing of nonstimulant medications and 74% reductions in overall polypharmacy. Despite these large reductions, there has been no increase in psychiatric hospitalizations.   These results have been sustained for more than a year with program use continuing for all foster children who are being prescribed a psychotropic medication.

Case Study 4.2:   Data Management and Physician Collaboration Leads to Improved Quality and Outcomes

A nationally recognized provider group with over 190,000 patients and 82 clinics develops the tools necessary to significantly impact the quality of care and provide timely reporting to clinical leadership.
The provider group, a network of primary care physicians and specialists, while known for high quality and low-cost care to a primarily elderly population, struggled with internal reporting to support performance improvement activities as well as submissions to CMS that did not accurately reflect the quality of care being delivered. Reporting was not accurate at the point of care and consequently, clinicians did not trust data to inform their decision making. The group had been providing monthly quality reports to their doctors, but the information was delayed, disjointed and not actionable.
An information delivery strategy was developed in close collaboration with the providers who were actually using the information. By creating a centralized hub of all relevant data and putting in place the governance necessary to ensure that all data was carefully reviewed and deemed worthwhile for clinical decision making.
Additionally, reports were simplified and focused on high levels of usability for the physician and clinical team. A monthly set of reports was customized for each provider and panel. The reports included process measures, outcomes benchmarked against peers and included care considerations as well as alerts for managing risk in particularly vulnerable patients.
The data was also valuable to clinical leadership, helping teams enhance care strategy, identify opportunities for process improvement and organization-wide initiatives and giving new perspectives on the population served. In the first year following rollout, HEDIS scores increased by an average of 20% and continued to increase on average 10% in the second year. Additionally, the reports are being continually improved with input from users to enhance functionality and accommodate new measures and initiatives.

Case Study 4.3: Improving Pharmacy Benefit Transparency

Physicians do not have real-time access to accurate patient pharmacy benefit information in work-flow. With the rapid adoption of electronic health records, electronic prescribing , increasing sophistication of pharmacy benefit structures, and formulary restrictions, physician’s require improved patient level pharmacy benefit information to promote medication adherence and appropriate drug utilization. Lack of physician access to patient benefit information creates downstream issues for pharmacies and PBMs and ultimately the patient suffers in these scenarios as many of them result in the patient not obtaining their prescription. Annually there are $289 billion additional costs to healthcare due to prescription non-adherence.
A pilot project is now underway to implement a pharmacy benefit inquiry platform that provides physicians with patient, pharmacy and medication-specific prescription benefit information in real-time during the prescribing process. When the physician selects the medication and the patient’s preferred pharmacy in the EHR, the product will return the patient’s out-of-pocket costs and other benefit information before the prescription is submitted.

With this system, the physician can see similar information a pharmacist sees when submitting a prescription to the health plan for coverage verification. Delivering this vital information directly within the physician’s workflow before the prescription is submitted can be a catalyst to dramatically improve adherence, enabling the physician to identify and address prescription-fill barriers that may hinder pick up at the pharmacy (e.g. product not covered, prior authorization required). In addition, the pharmacy receives direct benefit as they do not have to step out of work flow to address these issues that have been handled upstream before the patient arrives at the pharmacy.   The result bridges a significant gap in patient care.

Case Study 5.1: Reducing Readmission Rates through Technology

An integrated healthcare delivery network that serves more than 665,000 individuals through eight hospitals, 36 primary and specialty clinics, more than 500 physicians and providers and more than 1.2 million patient visits each year is using successfully using technology combined with nurse outreach to reduce readmission rates.

Research shows that discharge phone calls decrease post-discharge medication errors and help prevent infections. In addition, patients who receive detailed after-hospital care instructions are 30 percent less likely to be readmitted or visit the emergency room.   Previously, this system had staff nurses call discharged patients for follow-up, but found that success in reaching patients varied depending on the day’s workloads.  Now they use call center nurses in a centralized call center, who receive an electronic list of all patients discharged from the system’s hospitals, and attempt up to three calls within 72 hours of discharge to answer the patient’s or family’s questions and clarify discharge instructions.   The call center nurses can access the patient’s electronic medical records and can document advice and clinical interventions they provide to patients into the patient’s EMR.  As a result:

• The call center nurses are able to connect with more patients, contacting an average of 70 percent.
• This system’s rate of all-cause 30-day acute care readmissions is well below the national mean of 11.42 percent for hospitals of more than 400 beds, and their average length of stay is lower than average.
• Patients who receive a follow-up call are more satisfied with their overall experience. This is confirmed by higher measured patient satisfaction, with more patients who received a follow-up call ranking the hospital as a 9 or 10 where 10 is the best hospital possible.

Case Study 5.2:  Reduce Readmission Rates Through Remote Monitoring

 A large integrated delivery system has been able to show that their patients with chronic conditions can manage their health and avoid hospitalization by using telehealth equipment in their homes. Given their rapidly aging patient base, the system has chosen to prioritize working with patients to manage chronic conditions such as diabetes, hypertension and chronic heart failure.

The project involved using technology to obtain data from the home such as blood pressure and blood glucose, along with other patient information, and then merging that data into their electronic medical records system. This allows the patient’s health care team to monitor, anticipate and prevent avoidable problems. A recent study of the project, looking at health outcomes from 17,025 home telehealth patients, found a 25 percent reduction in the average number of days hospitalized and a 19 percent reduction in hospitalizations for patients using home telehealth. The data also showed that for some patients the cost of telehealth services in their homes averaged $1,600 a year – much lower than in-home clinician care costs.  In addition to cost savings, this type of partnership between patients and their medical team can delay the need for institutional care and help maintain independence for an extended time.

Case Study 6.1: Improving Patient Engagement Through Technology

90% of patients do not understand the information that doctors give them during the exam session.  Given this reality, it is vital for physicians to engage their patients through automated solutions in order to increase health literacy and promote trust between the physician and patient.  Technology is bringing patient centric content for news on provider websites, video news inside their waiting rooms, to breaking health news on social channels, mobile applications, and content for their health portals.  Each of these engagement channels are measureable at each point in the patient workflow.  This enables clinics to achieve greater efficiency of the patient visit pre appointment, as well as a stronger likelihood of medical adherence in post appointment.

In addition, meaningful use standards require hospitals to prove that 5% of their patients engage with their given health portals.  With many health portals, the lack of engaging content does not foster a user experience that keeps users coming back.    Automated delivery of patient-centric content through a technology partner, written at an appropriate level, reduces the administrative burden on providers while helping them to meet required standards for patient engagement.

Case Study 6.2: Remote Monitoring for Reducing Readmissions

A pilot project in North Texas has been focusing on using health information technology to lower chronic heart failure (CHF) readmission rates.   At most hospitals, CHF is the No. 1 reason for hospital readmissions.

The program monitors CHF patients remotely for 90 days after their hospital discharge.  Patients are equipped with tools to help identify potential complications that can result in readmissions. They are given vital-sign monitors, tablet devices and applications that link the data to the patients’ electronic health records (EHR). The wireless devices include a pulse oximeter, blood pressure cuff, and weight scale.

Patients use the devices to record their vital signs and use the tablet to send the data to their EHRs. They also complete a daily electronic questionnaire that can help flag symptoms that can lead to complications. Abnormal data or questionnaire answers send alert messages to designated provider smartphones and email addresses. In that case, a nurse calls the patients for more information. Physicians and other providers also have instant access to their patients’ status on the EHR.

Patients are selected based on the severity of their conditions. Some had been readmitted three to six times a year prior to the monitoring program.  Patients have responded well to technology and reaped lasting benefits beyond the 90-day experiment.  Overall, the initial results from the pilot show a reduction in the readmission rate from 14 percent to about 10 percent—a drop of 27 percent.

Case Study 6.3: Protecting Patients’ End of Life Care Plans through Technology

Published studies show that using technology to make high-quality advance care plans available and accessible for all adults helps ensure that a person’s goals and preferences for medical treatment are followed while simultaneously decreasing spending associated with medical care, especially in the areas of critical and end-of-life care.

Since October 2015, a North Texas company offering digital creation, storage, update and retrieval of emergency, critical and advance care plans (ECACPs) has been working with a private health information exchange (HIE) to offer digital emergency, critical and advance care planning to consumers in five states. Using health information technology (HIT) content and data transfer standards, the HIE has conducted more than 1,000,000 record queries for ECACPs on the company’s system. When an ECACP has been located on the system, it has been passed securely and seamlessly into the HIE repository, where it is available to doctors and hospitals 24 hours a day, 7 days a week, in the event of a medical emergency. When a search reveals that no ECACP exists in the technology company’s database, the HIE and the technology company have conducted an email outreach to the individual in question asking him or her to create one. The email outreach has been hugely successful, with outreach emails distributed to almost 100,000 patients, email open rates exceeding 80% and click-through rates to the online enrollment service exceeding 10%, a rate that is significantly higher than the adoption rates healthcare providers are seeing with other patient engagement tools like patient portals.

Case Study 7.1: Improving Infant Care Through Standard Based Electronic Reporting

Standards-based electronic reporting to newborn public health programs increases positive patient outcomes, saving time and money for hospitals. 1999 marked a watershed year for babies born in Texas. It was the year the Texas Legislature mandated screening of every baby for hearing loss, the invisible congenital disability that directly and personally affects children and families — as many as 15,000 children over a generation.  Undiagnosed or late diagnosed hearing loss can affect a child’s language, learning, and long-term productivity.  If hearing loss is identified at birth and children receive follow-up intervention services, they will learn language like their typically-developing peers and better that we can ever hope to teach it to them.

Reporting to public health and follow-up by public health have been in place, but studies have shown that follow-up can fail if contact information for the child is incomplete or inaccurate. In 2012, the state initiated a health information technology standards solution to this problem. The solution, based on the technical profile from Integrating the Healthcare Enterprise (IHE), is known as Newborn Admission Notification Information (NANI).  NANI accepts automated Internet-enabled reporting of newborn next-of-kin contact information from Texas birthing hospitals’ electronic health record systems, paving the way for achieving Meaningful Use Stage 2.  It sidesteps manual data entry that is redundant, inefficient and error-prone.  The new standards-based message implementation does all this unattended. This frees up time for hospital staff to take care of babies and means more infants receive needed care.

Case Study 7.2: Physician EMR Use Creates Efficiencies

Installation and deployment of a fully integrated electronic medical records system and a practice management system has had a number of positive effects on a Central Texas family medical practice. The system provides the practice with electronic charge capture at the point of care which, when combined with integration to a claims clearinghouse, has reduced collection days (the time from date of service to receipt of funds) by more than 70%, from 72 to 20 days.

Additionally, with better charge capture, the practice was able to significantly reduce lost charges.  Pre-EHR, they estimated that did not charge for about 32% of x-rays and vaccines. With the EHR that rarely occurs.  The positive financial impact of the system allowed them to recover their initial hardware and software investment in 26 months and increase overall provider revenue despite an 8% to 12% reduction of HMO/PPO reimbursement.

With the paper charts gone, the medical practice was also able to reclaim and remodel their chartroom for clinical functions, allowing the practice to double the number of providers and patient encounters within the same clinic space and reducing the per provider rent overhead by 50%. Improved processes have made their staff more productive. As an example, two experienced insurance specialists handle the entire filing and reconciliation of EOB’s for 9 full time providers with spare time to help with the phones. With greater efficiencies and higher reimbursement, this practice was able to allocate more resources to the practice to foster retention and improve customer service and patient care.

Case Study 7.3: HIT Brings Improved Efficiency in Lab Reports Delivery

A not-for-profit, integrated health system with over 1,500 physicians, a medical center, seven regional community hospitals, 140 different service sites, a large multispecialty medical group and a nationally recognized health plan used a health information exchange platform to improve the delivery of lab reports and results.

The system’s goal was to develop a solution that could be directly integrated with physician practices regardless of where they were on the technology adoption curve, as some providers had adopted an EHR while many others worked in paper-based practices. In addition, they faced a significant number of unhappy physicians who were overloaded with faxes and constant callbacks. At the time, the system was sending nearly 6,000 faxes to 1,600 physicians every day and with no capability to filter faxes – which not only was expensive and inefficient, but left physicians with a significant workflow challenge.

To accommodate the multiple care locations and diverse levels of technology maturity that exist across the health system, the system leveraged HIE technology using the same data feed to provide information via the web and via auto-print to paper-based physician offices – while offering discrete data integration with a myriad of EHRs to providers who were farther along the adoption curve and had successfully automated their practice and clinical workflow.

At this point, more than 800 physicians in 12 counties across more than 100 practices have been integrated into the HIE. Over 80 of these practices – representing more than 400 physicians – have been able to turn their faxes off completely. This has had a significant impact on workflow, operating costs and improved relationships with physicians.