Improving poison response with statewide HIE

Transcript - Improving poison response with statewide HIE

Dr. Suzanne Doyon: I had never seen, really in my lifetime -- and I've been doing this for 30 years -- a better tracking of these concentrations of this toxin and just better objective assessment of what was going on with the child.

Hannah Nelson: Welcome to Healthcare Strategies. My name is Hannah Nelson, assistant editor of Health IT and EHR. As digital health transformation progresses, statewide health information exchanges are playing a critical role in enabling real-time data sharing to support everything from care coordination to emergency response. For instance, Connecticut’s state HIE, known as Connie, is helping the Connecticut Poison Control Center at UConn Health access vital clinical data in real time, enhancing their ability to respond to toxic exposures.

Joining me today is Dr. Suzanne Doyon, medical director of the Connecticut Poison Control Center at UConn Health, to discuss how this data integration is strengthening emergency response efforts across the state. Dr. Doyon, thank you for joining me today.

Doyon: Thank you for having me.

Nelson: Now, just to start off, if you could give me just a brief overview of the Connecticut Poison Control Center, and its role in the state's healthcare ecosystem.

Doyon: Thank you for the opportunity to talk a little bit about the poison center, because we do a lot of good work, it goes mostly unnoticed. But what is it that we do, and how do we do it?

So first and foremost, I think the audience needs to understand the Connecticut Poison Control Center covers the entire state of Connecticut. There are no other poison centers in the state, but this one. We are physically located at UConn Health in Farmington, but we cover the entire state. We cover the entire state 24 hours a day, seven days a week, 365 days a year. We never, ever, not answer our phones. We are a phone-based system, so it's not as if we have little ambulances that go to the site of a poisoning and do stuff. It's not as if we do a lot of drug testing, or it's not as if we house even a lot of antidotes. Those are not the things that we do. What we do is provide phone-based help, for anybody and everybody who needs it. So, in a way, it was a form of telehealth -- because we've been in existence for 50 years or more -- it was a form of telehealth before telehealth was really a common word.

So, what do we see? By far, the most common poisoning we get called about is the little toddler, the little one and a half year old, two-year-old, that gets into a button battery, that gets into some kind of household chemical, that gets into a pharmaceutical product, a prescription product even. Those are by far the most common scenarios we get called about. But we also get called about attempted self-harms, when people overdose on medications to self-harm. And let's not forget, there's a bit of an increase of such behaviors in our teenage and our young adults right now, so this is a very hot topic right now.

But also, medication errors. We have a lot... We have a patient population, or a population that's getting older and older. Older patients are on medications, they tend to forget they took one, took a second dose of the same medication, this, that and the other. We call them medication errors, so we get called about them as well.

We get called about snake bites. We are the snake bites expert for the state of Connecticut. We get called about hazmat spills, or chemical spills, environmental issues, occupational issues, exposures. So we get called about any and all of these things, to the tune of about a hundred or so calls per day, sometimes a little bit more, sometimes a little bit less, and over 35,000 calls or so per year. Not all those calls are big, heavy-duty exposures that result in a lot of toxicity, but we are there to answer them. And we take care of the minor exposure and the major life-threatening exposure.

Nelson: Wow, that's incredible. A hundred calls a day is a lot of calls.

Doyon: Yes.

Nelson: So, I'm so glad you're here to talk about the work you guys do, and love to shine some light on it, because these are really important things that people need information about quickly. So, could you speak to this connection to Connie, and what were some of the challenges that you all faced at the Connecticut Poison Control Center before connecting to the state information exchange?

Doyon: This is just such an interesting question for me to answer, because it wasn't that long ago that we weren't connected to Connie. And again, not that long ago, what did a poisoning look like? We would be interested in using Connie for the more serious poisonings. And so, those would be the hospitalized patients, those would be the patients that are hospitalized in the emergency department, commonly known as the emergency room. But also, the ones that make it past, or beyond the emergency room; get admitted to a medical floor, maybe they get admitted to the intensive care unit. If we're talking about a child, we're talking about pediatric floor, pediatric intensive care unit, and these are the sickest of the sick. These are the poisonings that really need a lot of medical attention.

So, prior to having access to Connie, we might be called from the scene of the poisoning, or the poison center might be called from the emergency department, but we would hear about the poisoning in one or the other, or sometimes both of the settings. And then we'd take down the information: What did the patient get exposed to? How long did they get exposed to it? Obviously, how old the patient is. Does the patient have any prior medical illnesses that would really impact how this poisoning is going to take its course?

And then we start making recommendations from the very basic recommendations, such as what blood tests should be performed on the patient, what kind of imaging should be performed on the patient, to administration of antidotes or therapies to specifically address the issues of the poisoning. These emergency departments, these hospitals, are very busy. They are getting even busier than they were a year ago. And so, we would often make our initial recommendations, that's what we call them, and then wait an hour or two, and then we'd want to call back to see how the patient is responding. And then adjust, based on the findings.

And that's where we often ran into a little bit of an obstacle. These emergency departments are busy. We would call back two hours later, maybe nobody has the time to come to the phone, because they’re busy with their own emergencies. Maybe the patient was so, so ill that the patient's no longer in the emergency department; the patient is in some kind of intensive care unit, somewhere in the hospital. So now we have to hang up, figure out where in the hospital the patient is, just parachute in. A lot, a lot of time was spent just trying to get a hold of the provider, usually the physician, at the bedside, directly involved in the care of the patient. To, again, assess how the patient was a couple of hours ago. “What was done? How is this patient doing right now? What are we going to do for the next two hours or so?”

It was a real obstacle, and many times my staff was unsuccessful at contacting these physicians. And if we were lucky enough to contact these physicians, we would often have many questions besides, "How's the patient doing? What's the patient's blood pressure? Does the patient have a pulse?" These kinds of basic things. We want to know, "What's the latest blood test? Blah, blah, blah," whatever, fill in the blank. And many, if not the vast majority of the time, the response from the bedside physician would be, "I'm at the bedside right now. I'm not near a computer. I don't have the time to go to a computer, log in and find these lab values for you, so, I'm sorry, but I just don't have the answer to your questions." And so, we were left with big gaps, so to speak, big chunks of missing data.

And it might sound trivial, but I'm just going to use aspirin as an example. But when someone overdoses on Aspirin, let's say in a suicide attempt, or it's a little child that accidentally got into a bottle of Aspirin. And I'm really talking about Aspirin. Bayer's Aspirin. We have a very quick way of measuring Aspirin in the blood. Every hospital in the state of Connecticut can measure it very quickly. So, we would be interested in measuring it in the blood, and then we're interested in seeing where that measurement is two hours later. It's really critically important for us to know what those lab values are, again, in order to make the best recommendation moving forward.

But when we don't have access to that measurement of Aspirin in the blood, then we're really sailing without a compass, and it can lead to some bad decisions, some wrong decisions. And so, the fact that... This was just a way of life for us. And then, so what did we do? We call back and call back, until we found someone who was near the computer, who could give us some of the lab values that were really critical to patient care. So those were the kinds of obstacles we were running up against. And you might think that this only happened maybe once a day. It happened every hour of every day. When you cover a state the size of the state of Connecticut, 3.4 million people, I think. Yeah. It happens every hour of every day.

Nelson: That is wild. And to hear about all the challenges that you guys faced, trying to track down patient data and just the growing volumes of patients coming through emergency departments, it just seems like having that data must be really valuable and take away a whole part of the workflow that was taking up a lot of time, I bet. So that's super interesting.

Now just speaking about the different toxic exposure cases that you see, is there any kind of example that comes up that you'd like to share, where connecting to Connie has really come in handy and really made a difference?

Doyon: I was thinking about this, and I think the best example was a bread-and-butter case. That's what I'm going to call it, because it's so common.

Again, a little child. Like I said, we get called about little children all the time, about 50% of our calls. So it's a little 18-month-old, and he got into his parents' Synthroid. And a lot of your audience will know or understand Synthroid; it's one of the most commonly prescribed medications in the United States. It's a medication for the thyroid. They are very small pills, very tiny pills. So, children can actually ingest quite a few of them, because they're small pills. And so, the child ingested a hefty amount, and we asked the mom how much, and based on what the mom was telling us, it was going to be a hefty amount.

And so, just as I used Aspirin as an example, we can measure Synthroid in the blood. So, the child was referred to the emergency department where, we don't call it a Synthroid level, but a serum concentration of T4 was measured, and it was so high, it was off the charts. Really off the charts. And the child ended up being admitted for a few days, where it was persistently off the charts for a few days, until then it became within the range of measurable. But that T4 measuring is really only part of the story. We want to measure a secondary measurement, so to speak, the T3, and the T3 was very elevated throughout the hospital stay for this child.

After three, four days in the hospital, they discharged the child, and the child was then followed by the pediatrician. And the pediatrician, seeing the child in the office, called the poison center going, "Are you aware?" And we were like, "Oh, yeah, we're aware." And the pediatrician said, "Would you be able to give me all the lab values?" And we were like, "Oh, yeah. We have them; they're in Connie." And the pediatrician sent the child to get more of the same blood tests so we could follow the inpatient blood tests, that were drawn practically daily, we could follow them with every second day blood tests performed outpatient, and just watch and track this child for a total of nine days, 'til the child was out of the woods, basically.

It allowed for... I had never seen, really in my lifetime, and I've been doing this for 30 years, I had never seen in my lifetime a better tracking of these concentrations of this toxin in the child's blood. Better kind of cohesive management, better coordination between the hospital team, the poison center and the pediatrician, the practicing private practice pediatrician who took care of this patient -- better coordination I've never seen in my life. And just better objective assessment of what was going on with the child. So it was fantastic to see, really.

Nelson: Wow, that is amazing. It sounds like this connection is almost, it's a game changer in a way, for the way that you guys are able to follow up on these cases. And really cool, to see this HIE being used for this use case, is really amazing.

Doyon: It is what my staff calls it. It's the game changer.

Nelson: Oh, no way. I love it. That's perfect. Maybe that could be the headline. But this is so cool. I love to hear about the different use cases for HIEs that are a little bit not discussed as much, things that kind of fall by the wayside, and this seems like a really important, valuable use case that is being accomplished. So, really cool stuff.

Now in terms of efficiency of the staff at the center, could you speak to that, and just any time savings you guys have experienced? Or just general responses from the staff?

Doyon: Yeah, absolutely. And I think there are two ways to look at this. We have our own metrics, internal metrics at the poison center, to measure the performance of our staff. Since everything is telephone-based, it starts with the telephone calls, and the number of telephone calls, the amount of time spent talking to someone on the telephone, the amount of time spent documenting in our own documentation database, and so on and so forth. So, we have, bottom line, we have tons of metrics.

But one metric that we pay a lot of attention to is what we call follow-up calls. So, we were notified of this patient. The patient exists in some hospital, somewhere in the state of Connecticut. Now comes the time to follow up on the patient, see how the patient is doing, and adjust accordingly. And the number of follow-up calls has decreased by 50%, five-zero percent, which is a huge time saver. Less time dialing up a phone number, less time waiting with the hospital music, waiting to speak to a nurse. A lot, a lot less time wasted doing that, and more time spent doing what they like to do better, which is actually taking care of and managing patients. So, we actually have those metrics. We've reduced the number of follow-up calls by 50%, five-zero.

Staff morale, way up, way up. Because they're not waiting on the phone. This has happened to everybody, right? You wait on the phone for someone, and then the call gets dropped, then you have to try that again, so on and so forth. Less of that frustration with just trying to reach someone at the other end of the phone, so that's really improved employee morale or staff morale.

I think, also, on the other side, let's say I work in a hospital as a nurse or a physician, doesn't matter. That means less phone calls from the poison center, less interruptions. When the poison center calls and they say, "I'm not near a computer," the poison center will say, "That's okay, we have a back door to that. Tell me how the patient is. Is the patient awake, or is the patient still in a profound coma? Is the patient seizing, or has the patient stopped seizing? Are the patient's blood pressure and heart rate better, or are they still very bad? Let's focus on what the patient looks like at the bedside. Tell me with your eyes, and then all that computer stuff, all those lab tests, all those imaging studies, all that I can get through a different means if you're too busy to give me that information right now."

So I think from that standpoint as well, the standpoint of our hospitals, our hospital systems, there's an uptick in morale as well, from poison center, poisoning cases. So, it's been an overall very positive experience on many different fronts.

Nelson: Yeah, it definitely sounds like it. And to hear that staff morale is up is always such a great thing. So, really glad to hear that.

Now, in terms of ripple effects of this integration, are there any, kind of, trends that you guys have seen in terms of toxic exposure, or just areas where maybe more public health awareness is needed?

Doyon: We haven't quite been able... So, we've been using it for a little over a year, probably a year and three, four months. I'm sure; there've been a couple health issues during that time, we just haven't been able to pick them up. And I think the reason for that is the following.

So, we only know about the cases we get called about. As opposed to, for example, let's say I was a physician in private practice. I have a list of 300 patients that I'm responsible for. I can upload that list so to speak, to Connie, and then whenever one of those patients gets hospitalized or whatever, I can get a notification. It's a whole notification system. But that's not how poison centers operate. We only know about the patients that are poisoned. We don't know about the ones we don't get called about. So, it makes it a bit difficult to do surveillance when that's the case. So, we've had a little bit more difficulty.

Now, that being said, we get called about the rare stuff. For example, botulism is kind of a rare diagnosis. We haven't had a botulism case in the last 12 months or so. But if we were called about a botulism case, we would use Connie, really, to help us get a grasp of how sick the patient is and all that stuff. But we'd also dig a little bit in the Connie chart, look at, for example, the good histories that are in there: the good history takers. So, maybe the emergency department provider note, "May be botulism," tends to get them admitted to the ICU. So, the intensivists note, when the patient arrived to the ICU, maybe there's a resident note in there. These would be the prime people who take good histories. We would be digging into those to see, "Does a patient live by himself, or does a patient live with someone else? If they live with someone else, are we paying attention to that someone else? Could that someone else also have botulism? What can we find out about the living arrangement, the workplace arrangement, for that one kind of sentinel case to see if we have other people involved?

So that would be how we would use it. But as I said, botulism is rare, so we haven't had an opportunity yet to use it in the context of a botulism case, or something like that.

Nelson: Yeah, that's still super interesting, just another kind of way to use this connection and improve the health of people living in this state, which is obviously the goal. So, that's really cool.

Now, looking at this connection that you guys have made, could you see this being helpful for other agencies, or emergency services across the state?

Doyon: Absolutely. I do know that the Office of the Chief Medical Examiner, or CME, the Medical Examiner, is using, a fairly hefty user or big user of Connie. I think they find it very helpful as well. They do all kinds of death investigations. I do my own death investigations, but only for poisoning deaths, only the deaths that the poison center gets called about. But it's been incredibly helpful. So obviously, the people who die from their poisonings are not well, they're really ill during their hospital stay. And often, we throw just about everything at them, including the kitchen sink, to try to get them better. But our efforts sometimes fail, and they die.

But you want to make sure and use the health record to make sure that they died from the poisoning, and not something else. And the record is just incredibly important. You also get to see notes from the neurologist at the bedside, or the nephrologist at the bedside, or the cardiologist at the bedside. These are all the critical services that are usually involved in a poisoning. See what they were thinking, why they chose this instead of this. For example, a nephrologist might decide to not dialyze or might decide to dialyze a critically ill patient. But you see the thought process because they’ll put it in their notes.

So, the patient has died. So, when you're investigating the death to try to see, “Could we have done better? Did we miss, whatever?" Having access to Connie has been really helpful. In fact, it's neither here nor there, but every poison center has to do a write-up on every one of the poisonings it collects over the course of the year. So, I have to do that for the Connecticut Poison Control Center, and I believe it was for 2024, it might be 2023, I'm a bit off on my years, but with the use of Connie, I won for the entire country. Like, highest quality summaries.

But I'll tell you, quite frankly, the reason the quality of my summaries was good was because I had access to Connie, because I had access to all kinds of imaging, all kinds of lab tests, all kinds of cardiology notes and nephrology notes, that really were very helpful. So, it's really helped in my death investigations, to improve things, to figure out if we have issues in the state of Connecticut with any poisoning leading to an excess number of deaths, and so on and so forth. So, it's really been helpful.

I think OCME, as I said, also uses it a lot. I think every provider at the bedside, on occasion, wishes that they had access to the patient's records at the VA, or in a different health system that is not their health system. The big health system [EHR] is Epic, but what if the patient is seen in a hospital system that is not Epic? You don't usually have access to those records. So, to be able to access those records, really, is very helpful at the bedside as well. So, I think there's use for every hospital-based provider in the state, OCME, poison center. EMS probably would have a good use for it. But remember EMS, they're on the road, they're in the field. I'm not sure how good the internet access is on their devices, so there's a bit of connectivity issues there. So, I don't exactly know how the logistics of how that would work, but I'm sure they would be very interested in getting those records as well.

Every private practice physician in the state of Connecticut should sign up to be on Connie and use the tools available in Connie, the notification tools, to have a better handle on their patients when their patients are admitted to the hospital. And see what went on during the hospital stay and so forth.

Nelson: Yeah, that's amazing to see how data is being shared across all these different stakeholders, just for the purpose of improving patient care in the end, from the first phone call, and then to the death investigations that you do. How this is really driving quality up, and really cool to see.

So, my last question is just about, could this data sharing be a model for other states, other poison control centers, and how that could improve public health across the country?

Doyon: Absolutely. I can't speak enough of the impact, the positive impact, that Connie has had on the work of poison centers. The fact that it's real time, and it truly is real time, is priceless to us. We can't put a price on it.

No. 2, we have access to more and more data, it seems, every month, because hospitals are at different stages of uploading their information. Some hospitals upload their lab data, but not their imaging, for example, or this, that and the other. They're at different stages. But to have access to lab data, to have access to imaging, and then to have access to the provider notes, is just, again, priceless for us. And as you said, it really is a testament to trying to improve the quality of care.

I want to give another example, which again illustrates well the strengths of the poison center and the strengths of the treating physicians at the bedside. So, there are a couple of automotive products out there -- windshield washer fluid, radiator fluid -- that we get called about sometimes. And the ingredients in these windshield washer fluids and radiator fluids are measurable in the blood, which is, we like to monitor that in real time, but the lab test is only performed in one lab in the entire state of Connecticut -- at Yale. So, if a patient happens to be at a hospital other than Yale, then the test tube needs to be collected at the patient's bedside. But the test tube needs to be couriered, or taken to Yale, where Yale performs the test.

Now, as a poison center, we hear about these types of overdoses time and time again. We know exactly how much time Yale takes to run the test, because we're involved in all of them. So often, we know there's a little clock going on in our head. We're like, "Okay, Yale should have the result back in the next half hour," and it'll pop up in Connie. And we will see it, and then we will call the hospital and tell them what the result is, and they'll be surprised. "How do you know this?" We're like, "It's in Connie, for one thing."

But how do we know that it is in Connie? Because of our expertise in this matter, we know how long and the logistics of performing this very sophisticated test. We know how to do it. We know when to expect the result. They don't, at the bedside, but we do. And so, we are capable of expediting everything for them, and again, parachuting in when the lab result comes in, and then giving them the subsequent, "For the next two hours, for the next four hours, we'd like you to do X, Y, Z, based on the lab test that just resulted in Connie."

So, just again, a great coordination of care at the bedside, the expertise of the poison center, Connie entering in and making all this possible. But ultimately a great coordination of care, in real time, at the patient bedside.

Nelson: Yes. That is incredible. I'm so glad that you were able to come on today and chat with me. Thank you so much for joining us today, Dr. Doyon.

Doyon: My pleasure. My pleasure. I think it should be the model for, and I think it's going to be, the model for many, if not all states in the United States, in the coming years. So, thank you, and thank you for having me. And thank you for Connie. Thank you.

Nelson: My pleasure. Thank you.

Kelsey Waddill: And thank you, listener, for tuning in. If you liked what you heard, head over to Spotify or Apple and drop us a review. We'll be choosing some of our reviews to be read on the show in appreciation, so keep listening through to the end, because you might get name-dropped. See you next time.

Music by Kyle Murphy and production by me, Kelsey Waddill.

This is an Informa TechTarget production.