Characterizing Encounter Data for Patients Using an Indigent Medical Clinic

ORIGINAL RESEARCH

Characterizing Encounter Data for Patients Using an Indigent Medical Clinic Nadine Aktan, PhD, Joanne Fagan, PhD, and Craig Sorkin, RN ABSTRACT The purpose of this study was to characterize patient encounter data using an automated database system. Of the 1,963 visits characterized, a variety of acute and chronic conditions were prevalent. Expanding the database to include a system for mental health screening is recommended, as is strengthening partnerships with medical centers, nursing programs, businesses, and pharmacies. Characterization allows for planning of primary health care and assists with grant submissions and outcomes reporting. Nurse practitioners play a key role in providing health care services to indigent populations. The results of this characterization study will foster meeting these needs. Keywords: characterization, encounter data, indigent, nurse practitioner © 2012 American College of Nurse Practitioners

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he nurse’s role in the provision of primary care has received substantial scrutiny as demand has increased and nurse practitioners (NPs) have gained public support.1 NPs continue to play an integral role in the provision of primary health care services in a variety of populations, particularly indigent patients. Improving the health of minority patients depends, in part, on improving quality and reducing disparities.2 This study was the first part of a research program to explore ways in which the quality of health care services provided to indigent people could be enhanced. NPs can contribute significantly to this important area of applied research. Patient encounter data (PED) are health care use records based on provider visits with patients.3 Characterization of PED is essential to understand the multi-faceted health care needs of a population and more appropriately plan for their continual care. The primary investigator, an NP, along with the multidisciplinary research team, collected and analyzed data at a free-standing indigent medical clinic. This primary care clinic is 1 of 5 that offer free medical care in the state. All members of this large inner city in the Northeast and its neighboring communities are eligible to use the clinic’s services. 32

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PED were useful in characterizing the patient population. This approach of organizing and interpreting PED helped the health care team better identify the acute, chronic, and preventive health care needs of this community. Through this process the team can truly and effectively meet indigent needs. It has been reported that there are 3 components of encounter data quality—completeness, accuracy, and timeliness.3 This study is significant as it aims to ensure quality in these areas. Although such facilities as community health centers and free medical clinics play a key role in providing primary health care services to indigent people, many health care errors relate to a lack of availability of important patient information.4 Characterizing patient populations has also been found to be a useful predictive tool to individualize health care needs.5 By investing in information technology, such as computerized database systems, these facilities can promote safety and improve care. All health care team members must adapt to automated technology systems and incorporate them into care. When used efficiently and effectively, databases can help the health care team improve overall care. Attitudes toward computer usage have been explored in the literaVolume 8, Issue 1, January 2012

ture, and today more health care professionals have a positive attitude toward computers and report good or average computer skills, while younger professionals are more accepting of computer advancements.6 Characterization studies have been used by health care professionals for disease monitoring and surveillance to examine PED in areas such as immunization compliance, bioterrorism, and chronic conditions like asthma and diabetes. For example, a study conducted on immunization compliance trends using a computerized tracking system for 2 inner city clinics found that compliance rates were maintained over 90%.7 Another study on verifying the quality and consistency of immunization monitoring systems reported that inconsistencies in immunization data hamper the ability to manage immunization programs.8 Patients’ chief complaints at a large, urban, teaching hospital’s emergency department were analyzed as an opportunity to track bioterrorism and influenza, and computerized triage logs were found as a feasible method for surveillance.9 Findings were presented after examining an automated, broad-based, near real-time public health surveillance system using presentations to hospitals for 12 of 49 emergency departments in the Sydney metropolitan area. Here the authors also demonstrated the feasibility and potential utility of syndrome surveillance using routinely collected data from ED information systems.10 Characterization studies have been used to examine the population-level data of asthmatic clients. Researchers have characterized patients who suffer asthma exacerbations using data extracted from electronic health records (EHRs) and reported that race, body mass index, smoking history, and age at initial observations are predictors of asthma exacerbations.5 The authors report that these findings are consistent with previous characterizations of asthma patients in epidemiological studies and that data extracted by natural language processing from EHRs are suitable to characterize patient populations. Data from asthmatic clients have been further characterized to find that severe asthma is characterized by abnormal lung function that is responsive to bronchodilators, a history of sinus or pulmonary infections, persistent symptoms, and increased health care utilization.11 This type of information would be useful to predict trends in the general population. The literature presents diabetes and other conditions for which compliance is essential as areas crucial to evaluate in planning for and managing the health care needs of indigent clients. It was reported that less distrustful patients felt more www.npjournal.org

in control of their diabetes and had better physical and mental health in an indigent clinic at an academic medical center.12 They also found that medical mistrust was not significantly correlated to diabetic control, lipid control, or other outcomes in the same sample. Another research team examined quality of care at a pharmacist-managed diabetes service compared to usual care in an indigent clinic. Their study resulted in higher improvements in blood pressure control in the experimental group compared to the control group (both were statistically significant), decreased low-density lipoprotein-cholesterol levels in the experimental group, and significantly improved drug therapy in the experimental group compared to the control group.13 This latter review further explored the existing literature on patients who access health care services at free medical clinics. A previous qualitative study on 94 patients demonstrated there are 3 modes of attendance at free clinics: occasional, regular, and inconsistent.14 Here, the authors found that the relationships with staff and self-perceptions about asking for free care influenced attendance. These also affected how well the members of the target population were able to benefit from care. The results of this study and others point to the need for NPs and their colleagues who provide primary care to characterize these types of PED. Overall, the literature also suggests that automated technology assists health providers in collecting and managing information efficiently. This information, in turn, could be used for quality improvement, marketing, planning, or other purposes, and it is vital that health care professionals participate in these processes.15 NPs, along with members of the multidisciplinary research team, identified all of these as essential components of the effective provision of free health care services to the indigent community. METHODS The research team consisted of the primary investigator, a certified family NP (FNP), an epidemiologist, and an NP student, with feedback from the medical director and other practicing NPs. This multidisciplinary group of researchers participated in the creation and organization of a relational database. Microsoft Access was selected to organize and characterize PED because of its wide availability and easy use. This program’s fluent user interface and interactive design capabilities do not require deep database knowledge and help users track and report information with ease.16 The Journal for Nurse Practitioners - JNP

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The overall purpose of this project was to improve health outcomes of an indigent community. The initial intent of creating and organizing the database was to collect pertinent PED at check-in and again at discharge from the medical clinic. Adult clients from this inner city and its neighboring communities can access primary care services. Patients also present from a variety of inpatient and outpatient substance abuse recovery programs, as well as from homeless shelters provided by the agency. The PED collected would be analyzed to determine the current and future health care needs of the community members who use the clinic. It could then be used to ensure effective planning to meet those needs. Specifically, at the time of patient registration for each encounter, the following data were collected: a personal identifier, name, age, gender, race, and chief complaint. Then, again at discharge, an ICD-9 diagnosis code(s), a visit code, any procedures performed, and any medications dispensed or prescribed were entered. From this database, a variety of reports were then generated, such as client demographics, types of acute and chronic conditions managed, and pharmacological interventions. A retrospective chart review was performed by the research team to verify the reliability of all the information entered, organized, and characterized. Institutional review board approval was obtained. The information was gathered over a 9-month period and included 1,963 visits with 1,331 unique patients. The subsequent intent of study was to use PED to determine the future comprehensive needs of the clinic as plans for an expansion of health care services were developing. RESULTS The characterization of PED provided information on the demographic characteristics of the community seeking these free health care services. Of the 1,963 patient encounters documented, 86% were medical, 12% dental, and just over 1% employee health. The total of unique patients was 1,331, meaning each patient made 1.47 visits to the clinic over the 9-month period. Furthermore, 37% (n ⫽ 1,226) of the sample was male and 63% female (n ⫽ 732). The sample ranged in age from 18-77 years (mean ⫽ 41.13; standard deviation ⫽ 11.76), although most did not report their age; therefore, age was not recorded in the database (Table 1). Concerning race, 51% of the sample was black, 25% Latino, 18% white, and 6% other (Table 2). 34

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Table 1. Demographic Data—Age Age Range

Visits

Unique Patients

20-29

74

34

30-39

74

33

40-49

312

62

50-59

169

33

60-69

24

5

70⫹

1

1

Table 2. Demographic Data—Race Race

Total

Percentage

Black

1,005

51.2%

Latino

483

24.6%

White

360

18.3%

Other

110

5.6%

5

0.2%

Not Reported

The ranges of diagnoses seen at the clinic vary, but like most facilities providing primary care services, they include chronic disease, acute and chronic infections, and minor traumatic injuries. The primary chronic disease diagnoses include hypertension, diabetes, asthma, and arthritis; acute infections include bronchitis, dermatitis, sinusitis, and upper respiratory and urinary tract infections. Chronic infections, such as HIV and hepatitis, and mental health needs, such as substance abuse, depression, and anxiety, are also managed at the clinic. Table 3 includes the PED collected and characterized for diagnoses managed at the clinic. As outlined in Table 4, the medication management of these conditions includes antihypertensive and diabetic agents, inhalers and prednisone for asthma, and ibuprofen for arthritis, strains, sprains, spasms, and fractures. Controlled substances are not prescribed or provided in this facility because of the large number of clients with a history of substance use and abuse and for the safety of the patients and the health care team. For acute infections a variety of oral and topical antibiotics are prescribed and dispensed. DISCUSSION The results of this characterization study were significant in a variety of ways. First, the study will contribute to the literature on the importance of proper and automated documentation of patient intake and outcomes of PED. Findings will also play an integral role in planning for the advanced practice nursing, medical, and dental care provided to indigent Volume 8, Issue 1, January 2012

Table 3. Various Diagnoses Total

Percentage

Upper respiratory infection

32

2.3%

Urinary tract infection

22

1.6%

Bronchitis

28

2.0%

Sinusitis

15

1.1%

Rhinitis

23

1.6%

Dermatitis

34

2.4%

23, 28, 27, 18

6.8%

25

1.8%

Hypertension

194

13.8%

Diabetes

119

8.5%

Asthma

71

5.0%

Arthritis

22

1.6%

HIV

21

1.5%

Hepatitis

27

1.9%

Hyperlipidemia

19

1.4%

Gastritis

18

1.3%

Mental health: anxiety, depression, schizophrenia

7, 8, 2

1.2%

Substance abuse: alcohol, drugs, tobacco

2, 2, 14

1.3%

Routine exam

180

12.8%

No diagnosis

26

1.9%

Acute Condition

Pain: abdominal, back pain, sprain, spasm Headache Chronic Condition

Other Diagnoses

clients in the future. The results of a literature review demonstrate a gap in PED characterization of the indigent patients who seek health care services from free medical clinics. NPs are faced with addressing limited access to or participation in health promotion and disease prevention strategies, medical noncompliance, and lack of continuity of care from racial and ethnic disparities—all of which wellknown concerns when planning for and providing health care services to indigent populations. For example, it has been found that indigent minority women do not receive adequate breast cancer screening for many reasons, including cost. After an adjusted approach, screening attendance markedly improves.17 The findings of the present study www.npjournal.org

indicate that the proper development and implementation of an automated database to collect and interpret PED are beneficial in planning to effectively meet the acute and chronic health care needs of an indigent community. A surprisingly small number of psychiatric comorbidities and substance abuse presented in the community studied. A previous study conducted on the development and outcomes of a psychiatric pharmacy clinic for indigent patients found that this service in an underserved region appeared to benefit patients’ mental health and reduce cost.18 Researchers further developed and implemented a registry to collect data on women during pregnancy and the postpartum period to improve both diagnosis of mental health and substance abuse problems and access to mental health care during pregnancy. They found that a mental health registry that merges clinical and research needs can be successfully integrated into the obstetric clinic setting.19 The results of the present study demonstrate an awareness of the necessity to develop a system that will improve collection of PED on the mental health and substance abuse needs of the community in order to determine and implement interventions to better address their needs. This study presents the reader with a number of methodological concerns. First, because it was a descriptive study, there was no comparison group. Another methodological concern was that it explored retrospective data. Missing or incorrect data are concerns with this type of design. Incomplete information, transcription errors, inconsistency of providers, difficulties with the recordkeeping system, and poor handwriting on the paper log are additional methodological concerns. For example, the majority of age data were not recorded. Age data provided herein are given only to demonstrate ranges. The retrospective chart review was performed to address these concerns and to add to the validity of the characterization results to establish that completeness, accuracy, and timeliness of the PED reported. Study findings are consistent with previous characterization of the medical care of the indigent community. It was interesting to the research team to discover that each patient made an average of 1.47 visits to the clinic over the 9-month period studied. This low rate appears inconsistent with the level of chronic needs demonstrated by the data. Findings can be attributed to the nature of the indigent population, who may seek to have their health care needs met through a variety of resources, such as clinics and emergency departments. Further inquiry into this low repeat visit rate is needed. The Journal for Nurse Practitioners - JNP

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It has been found that this type of reporting can be optimized with automated technology because it provides a simple and efficient way to collect and report data.14 Overall, it has been found that few organizations take a systemic approach to data quality improvement, carefully considering how this information can affect the care it provides. Standardized data collection procedures, adequate supervision, reinforcement, and re-monitoring are key elements of an effective process.20 This organization sees this study as the first step in measuring quality and, in turn, implementing measures that ensure quality improvement. The next steps of this research program are to improve the automated database system, develop interventions to test based on the results of this characterization, and, most specifically, begin to explore means for funding and implementing EHRs. Many of these methodological concerns could be addressed through EHRs, systems into which providers themselves enter pertinent PED. NPs, along with their physician colleagues and all members of the multidisciplinary team, must demonstrate a willingness to adapt to and to use computer-based documentation systems. It has been found that academic medical centers partnering with outpatient clinic settings expand the primary care capacity of the services provided, combining advantages of a large and much smaller setting. These partnerships prevent health care delays and lower emergency department use.21 It has also been reported that a community-academic partnership can help to eliminate disparities by providing an on-site, interdisciplinary approach to the provision of primary health care services within an established and trusted community-based agency.22 Given the large numbers of acute and chronic needs of the community studied, future recommendations include partnering with local hospitals and medical centers, Board of Health departments, university medical and nursing programs, businesses, and pharmacies. In addition, after noting the small percentages of mental health needs and substance abuse reported, adding a mental health registry component to the database will facilitate the proper tracking of the psychological health needs of the indigent community and determining ways to better meet them. Getting psychology graduate, medical, or nursing students involved and providing public health student externships may be additional ways to provide these services. Other sources of funding improved mental health screening and services also will be explored. 36

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Table 4. Medication Categories Total

Percentage

Antibiotic

39

9%

Hypertension

71

16%

Diabetes

31

7%

Pain

49

11%

Asthma

25

6%

Spasm

10

2%

Allergy

23

5%

Skin

30

7%

Gastrointestinal

33

7%

Category Prescribed

Urinary tract infection

8

2%

Anti-fungal

13

3%

Depression

5

⬍ 1%

Smoking cessation

4

⬍ 1%

Cardiac

2

⬍ 1%

Seizure

4

⬍ 1%

Cholesterol

5

1%

Migraine

3

⬍ 1%

Vertigo

4

7%

Steroid

9

2%

Antiviral

8

2%

Antibiotic

45

14%

Hypertension

35

11%

Diabetes

11

4%

Pain

112

4%

Asthma

8

3%

Spasm

3

1%

Allergy

17

5%

Skin

7

2%

Gastrointestinal

13

4%

Urinary tract infection

38

12%

Anti-fungal

5

2%

Category Dispensed

This descriptive analysis of patient encounters will further be incorporated into grant applications to obtain financing for the projected needs of health care services to this population. PED will also be used to expand on the support the clinic receives from federal programs, such as Medicaid. Additionally, study findings will enable Volume 8, Issue 1, January 2012

the necessary preventive services to be offered to meet the Healthy People 2020 objectives. Given the fact that over 80% of the sample reported their racial background as non-white, it is important for the multidisciplinary team to address health care disparities. The Institute for Medicine (IOM) has called for health care organizations to increase their efforts to acquire and report race and ethnicity data. The results of this and future characterization studies will promote compliance with this calling. Although a large percentage of the sample did not have health insurance or Medicaid, Medicaid prescription data information has been used as a means of surveillance.23 Characterization also demonstrates that the population is relatively young, underscoring the need to continue health promotion and disease prevention strategies in the plan of care. By using Access and other means to collect, organize, and interpret data in the future, the acute and chronic health care needs of the medically indigent can be meet more efficiently and effectively. The IOM also has recommended better evidence in measuring the quality of health care. Patient databases of clinical information that is critical to evaluate care processes and outcomes can play a vital role in measuring quality. Through the characterization of health care data NPs and members of the multidisciplinary health care team can effectively foster the provision of primary care services for the indigent people.24 Overall, NPs are key players in providing quality care, both in the health care system of today and the everchanging, multifaceted system of tomorrow. By exploring evidence, these providers can effectively assist patients and their families in meeting their acute and chronic health care needs. The characterization of health care data is just the first step in enabling the practitioner to do so in an evidence-based way. The results of this characterization study have demonstrated a systemic means of addressing and managing the current and future health care services for the indigent community.

References 1. Fairman J, Rowe J, Hassmiller S, et al. Broadening the scope of nursing practice. New Engl J Med. 2011;364(3):193-196. 2. Bynum J, Fisher E, Song Y, et al. Measuring racial disparities in the quality of ambulatory diabetes care. Medical Care. 2010;48(12):1057-1063. 3. Sing M. Using encounter data from Medicaid HMOs for research and monitoring. 2004; Inquiry 41. 4. Hysong S, Sawhey M, Wilson L, et al. Improving outpatient safety through effective electronic communication: A study protocol. Implementation Sci. 2009;4(62). http://www.implementationscience.com/content/4/1/62. Accessed November 1, 2011.

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5. Himes B, Kohane I, Ramoni M, et al. Characterization of patients who suffer asthma exacerbations using data extracted from electronic medical records. AMIA 2008 Symposium Proceedings. 2008;308-312. 6. Emuziene V. Using computers for planning and evaluating nursing in the health care services. Student Health Technology Informatics. 2009;146:103-106. 7. Tung Y, Duffy L, Gyamfi J, et al. Improvements in immunization compliance using a computerized tracking system for inner city clinics. Clin Pediatr. 2003;42:603-611. 8. Ronveaux O, Rickert D, Hadler S, et al. The immunization data quality audit: Verifying the quality and consistency of immunization monitoring systems. Bull World Health Org. 2005;83(7):503-510. 9. Babcock C, Nouhan P, Rice K. Syndromic analysis of computerized emergency department patients’ chief complaints: An opportunity for bioterrorism and influenza surveillance. Ann Emerg Med. 2003;41(4):447-452. 10. Muscatello D, Churches T, Kaldor J, et al. An automated, broad-based, near real-time public health surveillance system using presentations to hospital emergency departments in New South Wales, Australia. BMC Public Health. 2005;5:141. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1361771/. Accessed November 1, 2011. 11. Moore W, Bleecker E, Curran-Everett D, et al. Characterization of the severe asthma phenotype by the National Heart, Lung, and Blood Institute’s Severe Asthma Research Program. J Allergy Clin Immunol. 2007;119(2):405-413. 12. Edge L, Michel Y. Medical mistrust, diabetes self-management, and glycemic control in an indigent population with type 2 diabetes. Diabetes Care. 2006;29(1):131-132. 13. Irons B, Seifert C, Horton N. Quality of care of a pharmacist-managed diabetes service compared to the usual care in an indigent clinic. Diabetes Technology Therapeutics. 2008;10(3):220-226. 14. Larson P. The complex self perceptions and relationships of patients who attended free clinics affected their attendance and ability to benefit from care. Evid Based Nurs. 2006;9(2):61. 15. Roberts L, Sward K. Birth center outcomes reported through automated technology. J Obstet Gynecol Neonatal Nurs. 2000;30(1):110-120. 16. Microsoft Corporation. Microsoft Office Access 2007 product overview. http://office.microsoft.com/en-us/access/HA101656301033.aspxs. Accessed October 12, 2009. 17. O’Brien T, Stevenson J. Improving breast cancer screening for indigent minorities: A county hospital cancer center’s experience. J Clin Oncol. 2007;25(18S): 17020. 18. Caballero J, Souffrant G, Heffernan E. Development and outcomes of a psychiatric pharmacy clinic for indigent patients. Am J Health-System Pharm. 2008;65:229-233. 19. Bentley S, Melville J, Berry B, Katon W. Implementing a clinical and research registry in obstetrics: Overcoming the barriers. Gen Hosp Psychiatry. 2007;29(3):192-198. 20. Maizlish N, Herrera L. Race/ethnicity in medical charts and administrative databases of patients served by community health centers. Ethnicity Dis. 2006;16(2):483-487. 21. Silberberg M, Yarnall K, Johnson F, et al. Neighborhood clinics: An academic medical center/community health center partnership. J Health Care Poor Underserved. 2007;18(3):516-522. 22. McCann E. Building a community-academic partnership to improve health outcomes in an underserved community. Public Health Nursing. 2010;27(1):32-40. 23. Chen J, Schmit H, Chang E, et al. Use of Medicaid prescription data for syndromic surveillance—New York. MMWR. 2005;54(suppl):31-34. 24. High-Value Health Care Project. How registries can help performance measurement improve care. 2010. www.rwjf.org/files/research/65448.pdf. Accessed November 1, 2011.

Nadine Aktan, PhD, RN, FNP-BC, is an assistant professor of nursing at William Paterson University and a family nurse practitioner in primary/urgent care in Wayne, NJ. She can be reached at [email protected]. Joanne Fagan, PhD, is a programs and grants specialist at Eva’s Village in Paterson, NJ. Craig Sorkin, BSN, RN, is nurse practitioner student at William Paterson University in Wayne, NJ. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest. 1555-4155/12/$ see front matter © 2012 American College of Nurse Practitioners doi:10.1016/j.nurpra.2011.06.002

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