Introduction
Increasingly, trauma centers are being encouraged to collect self-report outcome data from patients to capture key longitudinal injury outcomes.1–3 The American College of Surgeons Committee on Trauma may recommend the routine collection of outcomes, including physical and mental health symptoms, functional outcomes, and patterns of health service utilization, during the course of the weeks and months after injury. A series of large-scale trauma center prospective cohort and clinical trial investigations have relied exclusively on patient self-report to ascertain rates of physical and mental health symptoms, functional outcomes, and patterns of health service utilization.4–6 Increasingly, large-scale pragmatic clinical trials are being implemented in acute care medical settings and with injury survivors.7–9 Pragmatic clinical trials are designed to harness data collected in clinical settings under conditions of routine practice and encourage the use of real-time, workflow-integrated outcome data collection in the conduct of comparative effectiveness research.10 11
Leveraging large-scale electronic medical data collection is therefore an increasingly essential element of both acute care clinical and pragmatic trial longitudinal outcome data assessments.1 10–12 Health information exchanges represent one potential and currently underused source of large-scale electronic medical record (EMR) data in acute care medical settings.1 12–16 A key initial step in integrating health information exchanges into routine trauma center clinical and research longitudinal outcome assessments is understanding the accuracy of self-report health service utilization in comparison to real-time, workflow-integrated administrative data sources.
However, literature review revealed few studies that have compared self-report outcomes versus administrative data from a health information exchange. Specifically, one study examined acute care utilization in hospitalized patients with substance use disorders and documented consistent under-reporting of visits when comparing patient self-reports to objective emergency department (ED) exchange data sources.17 Similarly, in other areas of health services research, self-report utilization measures have been associated with recall biases,18 and it appears that error in recall increases as utilization increases.19 20 Additionally, previous studies have investigated acute care patterns of service utilization with administrative data in cohorts of patients at risk for high utilization.21 22 However, none of these studies are of trauma patients and many of these studies are limited to single health systems,23 whereas other studies include only a small geography that may cross health systems22 24 or are limited to one specific condition.17 25 To date, no studies substantiate the utility of administrative data from health information exchanges in documenting ED utilization patterns across broad patient populations and state-wide geographic regions, despite reliance on this measure to determine effective clinical outcomes for trauma surgery patients.
The Emergency Department Information Exchange (EDIE) is a type of health information exchange or care coordination platform that collects EMR information14 26 at the time a patient checks into any ED. Patients do not need to opt in or request their information be shared; rather, hospitals decide to participate for their entire population. For any patient, a hospital follows a standard registration process, and an admission, discharge and/or transfer message containing patient demographics is delivered to Collective Medical, which then packages health information on the patient and sends a notification to treating providers in the ED.27 The information package, or EDIE ‘alert’, generated at each ED visit includes counts of prior ED visits during the past 12 months and specific EDs visited, which is obtained through EMR data from each participating hospital. EDIE is unique for an intraoperability platform given its reach and spread across the country; as of June 2020, EDIE has participation in 99% of EDs in Washington and Oregon, as well as many sites in California and over 20 other states across the country.28
The objective of this article was to first assess the patterns of past 12-month state-wide ED utilization among a cohort of injured patients admitted to a level I trauma center with comorbid medical, psychiatric and substance use conditions using EDIE. Next, the investigation compared self-report ED utilization with EDIE-documented ED visits to assess patterns of patient over-reporting and under-reporting. Finally, the investigation aimed to determine if there were patient demographics or clinical characteristics associated with the over-reporting or under-reporting of ED utilization.