Fragmentation of medical information: Study of adult acute care visits finds many patients visiting multiple sites

The researchers, publishing in the December 13/27 issue of Archives of Internal Medicine think their findings make a strong case for investing in health information technology.

"We specifically chose to look at the acute care setting because it is there that the patient first interfaces with a health care provider, who needs relevant clinical information immediately to make informed decisions," says Fabienne Bourgeois, MD, MPH, of Children's Division of General Pediatrics and the study's first author. "The acuity of patients presenting leaves little time for providers to track down relevant clinical information; this is a scenario where an integrated source of health information could be of great value."

In the study, Bourgeois and colleagues Kenneth Mandl, MD, MPH, and Karen Olson, PhD, of the Children's Hospital Informatics Program and Division of Emergency Medicine focused on visits from 2002-2007 to emergency departments, inpatient units and observation units at 77 nonfederal acute care hospitals and satellite emergency facilities. They collected data from three databases managed by the state's Division of Health Care Finance and Policy on a quarterly basis, and tracked patients via unique health identification numbers (UHINs) assigned from social security numbers.

Of the 3.6 million adult patients visiting an acute care site, 1.1 million (31 percent) visited two or more hospitals during the study period and accounted for 56.5 percent of all acute care visits. The authors also identified a subgroup of 43,794 patients (1 percent) that visited five or more different hospitals, accounting for roughly one-tenth of all acute visits.

"The number of sites that some patients went to for acute care astonished us," says Mandl, senior author on the study. "For the first time we showed just how common it is to go across sites of care, and now understanding this, we can look at the issue of information fragmentation and demonstrate the critical value of making vital health information accessible across settings."

Compared with patients with repeat visits to the same site, the researchers found that patients visiting multiple sites tended to be younger, were more likely to be male, were more frequently hospitalized, incurred higher charges at any one visit, and were more likely to have a primary psychiatric diagnosis listed as the reason for their visit.

"It is significant to find that the odds of having a primary psychiatric diagnosis were higher among individuals who were seen at multiple sites of care, because studies have shown that this population is at particular risk for medical errors and adverse events," says Bourgeois. "At a broader level we know that treating patients with incomplete information can expose patients to medical errors, adverse events, duplicative tests and higher costs."

The authors note that they were not able to directly assess the consequences of fragmentation in their study, but because of the length of the study period and state-wide scope of the research, believe they were able to establish that a large number of patients navigating multiple health care systems are exposed to the risks of fragmented medical information, at least in the acute-care setting.

The study did not address non-acute, outpatient visits and the level of fragmentation including primary care and specialists, the researchers note.

"What we found is clearly just the tip of the iceberg and shows us that the problem is probably bigger than we thought," says Mandl. "It provides a great case for justifying the billions of dollars that are being invested in health IT and influencing how IT systems, personally controlled health records, and regional health information exchanges are built. There are clearly a great number of concrete benefits to solving the problem -- improved continuity, safety, quality of care and cost."

The study was funded by the Health Resources and Service Administration, the Centers for Disease Control and Prevention, and the National Institutes of Health's National Center for Research Resources.