The goals of the Emergency Department and Hospital-Based Data Exchange for Real-Time Data to Care (ED Alert) intervention are to reengage people with HIV in care and to improve viral suppression rates. This is achieved using a real-time data exchange system that connects clients presenting to the emergency department (ED) with health department linkage specialists. ED Alert increased viral load testing and viral suppression over six months following a provider visit in the post-intervention period.
Seattle, WA
ED visits present a prime opportunity to reengage people with HIV in care, especially as there is evidence that people with HIV disproportionately access the ED for medical care due to insurance status and comorbid conditions, including substance use disorders or housing insecurity.1 In 2015, the University of Washington (UW) Medical Center partnered with Public Health - Seattle & King County (PHSKC) in Washington state to create and implement a real-time data exchange system that is activated when people with HIV with a detectable viral load (>200 copies/mL) present to the ED at hospitals within Seattle and King County. The data exchange system cross-evaluates client data with public health department data to begin the process of reengaging these clients into care.
The PHSKC real-time data exchange scans the UW Medicine Enterprise Data Warehouse every five minutes to identify patients presenting in the ED and inpatient units. Alert-eligible visits were defined as visits for people who 1) were in the hospital on a weekday between 8:00 am–6:00 pm; 2) had any previous positive HIV laboratory tests; and 3) had a last recorded viral load that exceeded 200 copies/mL prior to their visit. If a client is eligible, the data exchange sends a short messaging system (SMS) notification to the PHSKC HIV care re-linkage team to facilitate linkage to care.
The re-linkage team receives client information using a SQL Server Reporting Services (SSRS) report, which is available through the UW Medicine network and updated in real time. The re-linkage team reviews the SSRS report as soon as possible after receiving an SMS alert, typically within a few hours. Client information remains on the report until the client is discharged. After reviewing the alert and client information, the re-linkage team contacts the nurse caring for the client to check on the client’s health status, and, when possible, meets with the client while they are in the ED or hospital to discuss HIV care reengagement. The re-linkage team also identifies barriers to care, assists with making a follow-up appointment, and links the client to supportive services. The HIV care re-linkage team consists of disease intervention specialists with expertise in providing HIV care engagement assistance.
Researchers from the University of Washington conducted a pre-post study, comparing viral load testing and viral suppression in the two years prior to ED Alert implementation to the two years post-implementation. ED Alert increased viral load testing and viral suppression over a six-month period following a provider visit in the post-intervention period.
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*statistically significant |
Source: Avoundjian T, Golden MR, Ramchandani MS, et al. Evaluation of an emergency department and hospital-based data exchange to improve HIV care engagement and viral suppression. Sex Transm Dis. 2020;47(8):535-540.
Characterize available health data. Implementing a data exchange intervention requires a clear characterization of the data elements available through the health system in the jurisdiction. This means having a well-defined picture of available client data, reporting frequency, data sources, variables of interest for the data exchange, existing data sharing agreements, and the type of software needed to support data exchange activities.
Stakeholder buy-in. The implementation of this intervention requires approvals between partnering organizations to ensure the safeguarding of client data. This includes the establishment of data sharing agreements, standard operating procedures, and privacy protocols. Since this intervention is applied within the clinical ED setting, it is important to obtain support from nursing staff to ensure that re-linkage efforts can coincide with the ED care that staff are providing to clients. Gauge organizational capacity to hire the necessary staff to implement the intervention and ensure support from clinical staff.
Assess and address gaps in staffing and workflow. The role of re-linkage specialists (disease intervention specialists and health department HIV re-linkage specialists) and reliable information technology (IT) administrators are critical to implementing this intervention. It is essential to have staff members who can oversee the development of the data exchange system, and that there is sufficient buy-in from the in-house IT department to help facilitate system development. IT staff should be familiar with the health data infrastructure in the jurisdiction and be available to assist with technical issues as they arise.
Set up the data exchange. The goal of the intervention is to use a real-time data exchange system that gathers available health system data to determine whether a client who presents to the ED has a previous positive HIV laboratory test and a viral load of >200 copies/mL. An automated alert is then developed that notifies health department HIV re-linkage teams. Ensure that the system can identify people who are not virally suppressed or have not received a viral load test within a three- to six-month period and can reliably extract this data to create alerts.
Develop the alert algorithm. Understand the characteristics of the local client population to determine what metrics are critical to include in the alert algorithm. There is some flexibility in how to approach this aspect of the intervention. Determine the most consistent barriers to care engagement within the local population base and develop an electronic medical alert system around clinical outcomes most affected by those barriers. Determine an alert window (e.g., 8:00 am–6:00 pm Monday–Friday) that will maximize the opportunity to re-link clients to care and that aligns with staffing capacity.
If needed, recruit a re-linkage team. If an existing re-linkage team or specialist, such as a disease intervention specialist (DIS), is not already in place, prioritize the hiring of health department linkage specialists who will comprise the re-linkage team. This team will connect with the client to begin re-linkage to care once an alert is received through the data exchange system. While this intervention was not created to serve a specific population, it is important that the re-linkage team is representative of or shares the lived experiences of the population(s) served to ensure the intervention’s success.
Train ED and re-linkage staff: Staff training necessitates an understanding of the data exchange system and how alerts are triggered, and how to engage clients with various lived experiences. It is important that staff are trained in trauma-informed approaches as ED visits can occur due to both medical and circumstantial client experiences.
- RWHAP Part A and Part C funds were used to support linkage activities within the medical center complex. Data exchange development and evaluation of the intervention was funded by the University of Washington’s Institute of Translational Health Sciences. Facilities and resources were provided by the Harborview Medical Center, University of Washington Medical Center, and Northwest Hospital & Medical Center.
- It is not possible to effectively implement this intervention without obtaining buy-in at the leadership and managerial levels across all key stakeholders required for data exchange and re-linkage activities.
- Identify a champion within the organization who believes in the intervention, can highlight the benefits of the intervention and can promote it to leadership while maintaining momentum and staff morale.
- In cases where a dedicated administrative coordinator or data manager are not available, staff may find it difficult to balance and maintain the monitoring of alerts and client data while also being involved in direct service. Be clear on all staff roles and responsibilities and recruit dedicated people to fill these roles to streamline workflow and promote sustainability.
- The re-linkage specialist, administrative coordinator, and data manager are important for program continuity. Hire dedicated staff for each of these roles who are solely responsible for their specific duties. Train other staff on key duties as part of succession planning should there be staff turnover. Ensure that the collaborating organizations have existing staff in place to maintain the data exchange system.
- Gather information about current clinic data-sharing policies and lessons learned from other interventions to improve the data-sharing process.
- Ensure data extraction and data matching is conducted in a timely manner. By improving the timeliness of data sharing, the health care organization can ensure that, for example, it has the most up-to-date client information, which can facilitate prompt re-linkage efforts.
