Establish an Emergency Department and Hospital Discharge Monitoring System in Montana

1. Establish an Emergency Department and Hospital Discharge Monitoring System in Montana Todd S. Harwell, MPH Montana DPHHS

2. Why make hospital and ED discharge data reportable? • DPHHS mission - to improve the health status of Montanans to the highest possible level. • A cornerstone activity to achieve this mission is to conduct public health monitoring to determine the health status of Montanans. • Monitoring is critical to guide our actions to improve health and inform policy deliberations and legislation. • Existing data sources are available to help achieve this goal (e.g., vital records, cancer registry). • The major gap in our ability to effectively assess the health status of Montanans is the absence of timely, thorough, morbidity data.

3. What are other States doing? • Multiple other States have successfully implemented ED and hospital discharge data monitoring programs. • As of 2007, the majority of states (39 including the District of Columbia) have legislation in place to require reporting of hospital discharge data. • Twenty-eight of those states collect hospital discharge data directly, and 11 contract with private organizations (e.g., hospital associations) for data collection. • Twenty-seven states are collecting ED data. • Important health information derived from hospital discharge and ED data in those states should also be readily available in Montana.

4. What currently is being done in Montana? • Montana Hospital Association has a voluntary hospital discharge data program established since 1999. • Majority of non-Federal hospitals provide electronic hospital discharge data to a contracted MHA vendor who processes these data and provide minimal reports to MHA and participating hospitals. • Data are collected from the UB billing form used by hospitals to bill for services. • Data have some major limitations: • ED data are not systematically collected • Indentifiers are not collected (unduplicate recurrent events) • E-codes, used to define the specific cause of an injury (e.g., diagnosis = skull fracture; cause of injury = occupant in a motor vehicle crash) are not systematically collected • Race/Ethnicity information is not collected • MT DPHHS has an agreement with MHA and purchases the existing hospital discharge data set.

5. An example of the limitations to the current monitoring system in Montana • Number of deaths due to unintentional poisoning in Montana has been increasing over the past 8 years. • Using death records we can tell that this increase began in 1999, and that the use of prescription drugs (e.g., methadone, oxycodone) is related to this increase. • However, important morbidity data to investigate this problem for the general Montana population are not available. • Lack of systematic collection of e-codes in the hospital discharge data set, and the lack of ED data prohibit this type of investigation.

6. What essential improvements should be made to this system to increase the quality and usefulness of hospital and ED data? • Data improvements: • Collect identifiers for each case to un-duplicate the admission events, and provide a mechanism to identify repeat/recurrent health events as well as link these data sets to other data sets such as death records. • Ensure completion of the e-code fields that define the exact cause of injury to allow for analyses focusing on injuries, a leading cause of death in Montanans aged 1 to 44. • Get access to data fields for Zip code and cost information to conduct more detailed geographic analyses and population-based cost-related studies. Key variables needed already exist on the UB form. • Collect data regarding race/ethnicity. • Establish ED discharge data collection system that includes/address the above.

7. Confidentiality and HIPAA • As with all public health monitoring data, this information would be analyzed in aggregate, maintaining individual patient confidentiality and strictly following federal and state standards such as HIPAA. • DPHHS collects identifiers for other reportable conditions including communicable diseases, cancer, live births, and deaths and has had no issues or problems with maintaining patient confidentiality.

8. Next Steps • DPHHS is submitting legislation to require ED and hospital discharge data reporting to the Department. • DPHHS has submitted a request for $150,000 to support 1 FTE epidemiologist and budget for this program. • Work collaboratively with MHA and the hospitals to enhance the existing data collection system in Montana. Oregon state has taken a similar approach. • Targets: • By June 2010, all hospitals in Montana (excluding Federal and State hospitals) will submit hospital discharge data to DPHHS. • By June 2011, all hospitals in Montana (excluding Federal and State hospitals) will submit emergency department discharge data to DPHHS. • Ongoing, DPHHS will publish and disseminate quarterly reports utilizing the emergency department and hospital discharge data to assess the health status of Montanans. • Ongoing, DPHHS staff for this program will work collaboratively with other state and local public health programs, and other health organizations to support the utilization of emergency department and hospital discharge data.

9. We should be able to do this! Table 2. Pediatric emergency department (ED) rates for asthma by race/ethnicity, New Jersey, 2004-2005.* *Kruse LK, et al. Disparities in asthma hospitalizations among children seen in the emergency department. J Asthma 2007;44(10);833-837. Data source – NJ ED and hospitalization data files 2004-2005, children aged 1-19. Includes children seen in ED only plus children hospitalized from the ED.

10. Do Montanans support a primary seat belt law?