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The PaTH (University of Pittsburgh/UPMC, Penn State College of Medicine, Temple University Hospital, and Johns Hopkins University) clinical data research network initiative is a collaborative effort among four academic health centers in the Mid-Atlantic region. PaTH will provide robust infrastructure to conduct research, explore clinical outcomes, link with biospecimens, and improve methods for sharing and analyzing data across our diverse populations. Our disease foci are idiopathic pulmonary fibrosis, atrial fibrillation, and obesity. The four network sites have extensive experience in using data from electronic health records and have devised robust methods for patient outreach and recruitment. The network will adopt best practices by using the open-source data-sharing tool, Informatics for Integrating Biology and the Bedside (i2b2), at each site to enhance data sharing using centrally defined common data elements, and will use the Shared Health Research Information Network (SHRINE) for distributed queries across the network.

Objective: To examine the impact primary care referral has on subsequent emergency department (ED) utilization. Methods: Uninsured ED patients who reported not having a primary care (PC) provider were referred to PC services at a community health center (CHC). The number of CHC visits completed was documented and the utilization rates of hospital-based services (i.e., ED visits, outpatient clinic visits, and admissions) were compared for patients who completed a CHC visit and those who did not before and after referral. Results: Of the 655 referred patients, 22% completed at least one CHC visit. Patients who completed a visit were more likely to be older, to be female, and to have a chronic medical problem (p = 0.001). The number of visits to the CHC was significantly related to the payment method. Only 19% of those who were self-pay completed three or more CHC visits, compared with 63% of those who qualified for a sliding fee or insurance (p < 0.001). There was no significant difference in pre- or post-ED utilization between those who completed a CHC visit and those who did not. The only significant difference in utilization between the two study groups was for subsequent outpatient visits. Patients who completed a CHC visit were more likely to receive outpatient specialty care (23%) compared with patients who did not (12%) (p = 0.001). Conclusions: For uninsured patients with no regular health care provider, improving access to primary care services is not enough to reduce their visits to the ED.

To examine the impact primary care referral has on subsequent emergency department (ED) utilization.Uninsured ED patients who reported not having a primary care (PC) provider were referred to PC services at a community health center (CHC). The number of CHC visits completed was documented and the utilization rates of hospital-based services (i.e., ED visits, outpatient clinic visits, and admissions) were compared for patients who completed a CHC visit and those who did not before and after referral.Of the 655 referred patients, 22% completed at least one CHC visit. Patients who completed a visit were more likely to be older, to be female, and to have a chronic medical problem (p = 0.001). The number of visits to the CHC was significantly related to the payment method. Only 19% of those who were self-pay completed three or more CHC visits, compared with 63% of those who qualified for a sliding fee or insurance (p0.001). There was no significant difference in pre- or post-ED utilization between those who completed a CHC visit and those who did not. The only significant difference in utilization between the two study groups was for subsequent outpatient visits. Patients who completed a CHC visit were more likely to receive outpatient specialty care (23%) compared with patients who did not (12%) (p = 0.001).For uninsured patients with no regular health care provider, improving access to primary care services is not enough to reduce their visits to the ED.

Article-at-a-Glance Background In 1998 the emergency department (ED) Work Group at Johns Hopkins Bayview Medical Center (Baltimore) worked to reinvigorate the fast-track program within the ED to improve throughput for patients with minor illnesses and injuries who present for care. There had been two prior unsuccessful attempts to overhaul the fast-track process. Methods The work group used a change model intended to improve both processes and relationships for complex organizational problems that span departments and functional units. Before the first work group meeting, the work group evaluated the institutional commitment to address the issue. The next step was to find data to fully understand the issues and establish a baseline for evaluating improvements—for example, patients with minor illnesses and injuries had excessively long total ED (registration to discharge) times: 5hours 57minutes on average for nonacute patients. Online and offline meetings The work group identified process problems, but relationship barriers became evident as the new processes were discussed. Yet offline work was needed to minimize the potential for online surprises. The work group leaders met separately in small groups with nursing staff, lab staff, x-ray staff, registrars, and physician's assistants to inform them of data, obtain input about process changes, and address any potential concerns. The group conducted four tests of change (using Plan-Do-Study-Act cycles) to eliminate the root causes of slow turnaround identified previously. Results Total ED time decreased to an average of 1hour 47minutes; the practice of placing nonacute patients in fast track before all higher-acuity patients were seen gained acceptance. The percentage of higher-acuity patients sent to fast track decreased from 17% of all patients seen in fast track in January 1998 to 8.5% by February 1999. Patients with minor illnesses and injuries no longer had to wait behind higher-acuity patients just to be registered. The average wait for registration decreased from 42minutes in January 1998 to 14minutes in February 1999. Physician's assistant, nursing, and technician staff all report improved working relationships and feeling a team spirit. Discussion The offline component of the integrated model helped to improve organizational relationships and dialogue among team members, thereby facilitating the effectiveness of online efforts to improve processes. This model has also been applied to improve patient registration (revenue recovery) and the emergency transfer and admissions process.