The need for a national emergency health services database

EM Advances

CJEM 2008;10(2):120-124

Abstract

Résumé

Introduction

Emergency departments (EDs) in Canada are under enormous strain because of a reduced number of inpatient beds (resulting in overcrowding), a shortage of primary care physicians and changing patient demographics. Overcrowding itself is a key issue facing the Canadian health care system.1To reduce overcrowding, we must have a better understanding of its causes thus making the collection and analysis of administrative data critically important. Administrative data refers to information collected "usually by government, for some administrative purpose (e.g., keeping track of the population eligible for certain benefits, paying doctors or hospitals), but not primarily for research or surveillance purposes."2

Two Canadian emergency health services (EHS) administrative databases were of particular interest to our research group: the Alberta Ambulatory Care Classification System (ACCS) and the National Ambulatory Care Reporting System (NACRS). ACCS was developed by Alberta Health and Wellness. NACRS was developed by the Canadian Institute for Health Information (CIHI) using the ACCS as a base. At the time of the study, Ontario was the only province that had mandated submission to NACRS. These 2 EHS administrative databases are similar in some respects and dissimilar in others. For example, NACRS mandates collection of triage information (i.e., date, time and triage level), reason for visit, visit type, seat belt and helmet indicators, and Glasgow coma scale score; however, ACCS does not. Currently Canadian institutions collect many of the data elements recommended by the Canadian Emergency Department Information Systems Working Group.3

Researchers use EHS administrative data to provide information to policy- and decision-makers, program managers, service providers, and public health officials and planners.4-8 EHS researchers monitor changes in practice patterns, identify regional differences and identify risk factors for injuries.9,10 They investigate the outcomes associated with alternative methods of treating individuals in the ED and recommend changes designed to improve patient management and increase efficiencies.11-13

There is great potential for these 2 EHS databases to be used to help change practice, develop health policy and influence resource allocations.1,14-20 However, data published by Rowe and colleagues suggest, from the perspective of Canadian ED directors and provincial and territorial ministries of health representatives, that this potential is largely unrealized.20 A study by this group concluded that serious barriers exist because of the wide variety of data collected and the ways in which collection was done. These limit the ability to compare ED services across the country. The authors stated that "there is an urgent need to place the collection of ED information on the provincial and national agenda and to make collecting the information consistent, comprehensive and mandatory."20

To date, there has been limited discussion in the published literature about the strengths and limitations of the EHS administrative databases from the researchers' perspective. It is important that researchers' perceptions be captured because they may differ in important ways from the perceptions of other stakeholders (e.g., Canadian ED directors, regional health authorities, representatives from the provincial and territorial ministries of health, and electronic ED information systems vendors). Researchers are unique in that they design studies to compare populations over time or across geographic areas. Our objective was to collect rich qualitative data from a small nonrepresentative sample of 4 carefully selected knowledgeable health services researchers on what they perceive to be the strengths and weaknesses of Canadian EHS administrative data.

Methods

In this exploratory study we collected data between February and March 2006 from a convenience sample of 4 Canadian health services researchers about what they perceived as the strengths and weaknesses of EHS administrative data, their views on EHS research data needs and the usefulness of the data. We recorded their suggestions about how to improve usability, accuracy, timeliness and comparability.

Approval for the interviews was obtained from Sunnybrook and Women's Health Sciences Centre, Research Ethics Board. We selected 4 researchers who had:

• familiarity with and the use of EHS administrative databases;

• knowledge of priorities relating to EHS administrative databases; and

• involvement in health services research.

The principal investigator provided the 4 researchers with the interview guide before their semistructured interview and prepared an opening statement outlining the research question. All interviews lasted 30 to 40 minutes.

Using conventional approaches for the analysis of qualitative data developed in the 1940s by Merton and his colleagues,21 we examined the transcripts, grouped ideas together and, subsequently, had other members of the team re-examine the groupings. These groupings were finalized after 2 coders agreed on the groups. Interviewees were asked to review the analysis and presentation of data to ensure that their comments were accurately reflected.

Results

Five common themes emerged from the interviews: data use, linkage, data quality, clinical detail and population coverage. The interviewees' ratings of the strengths and weaknesses for the 5 themes are provided in Table 1.

Data use

Overall, data use, or the ability to answer vital health services research questions, was considered a key strength of EHS administrative databases. All the interviewees believed that there were many questions that could and should be answered using EHS administrative databases. Each provided summations of studies they had completed or were planning to do, for example, an analysis of health services use before, during and after severe acute respiratory syndrome (SARS).

Linkage

The linkage between EHS databases and other administrative databases, such as physician claims, is the second key strength that was identified. One interviewee described several types of linkages they had performed "internally to count patients versus visits, to follow patients over time and for multiple visits, to link back to previous patient visits for missed diagnoses and also to the discharge abstract database to check on admissions." Another interviewee summarized the need for data linkage this way:

We need to be able to link this back to some mother ship that says this person lives in this environment, their average income is $42 000, they last presented to the emergency department 3 years ago with their asthma, they subsequently saw their family doctor for 2 days after being seen in the emergency department and saw a consultant 6 weeks later. They haven't been back in an emergency department for the last 4 years. That's the power of it.

Data quality

The interviewees believed that data quality (e.g., standard definitions, sufficient edits, standard training, and support for data collectors and users) was a weakness that needed to be addressed. One interviewee indicated that for published analyses, "some institutions had to be excluded due to data quality issues," meaning the institution had too much missing data.

Clinical detail

The interviewees said that the clinical detail of existing EHS databases is insufficient. One felt that the "lack of clinical detail was a major weakness." The same interviewee stated that it must be recognized that the EHS administrative databases are

for multiple uses and not designed for research purposes, so in some ways we are trying to turn a car into a boat. If the data custodians are responsive to making alterations to the database, they are not the ones ultimately gathering the data, so they have limited leverage on the actual collectors, which are the hospitals.

Population coverage

Finally, the interviewees observed that although the submission of EHS data to CIHI is mandatory in Ontario, national Canadian EHS data is missing. Unlike inpatient data, population coverage is lacking for EHS data. One interviewee stated, "I would do anything to move a national agenda forward. I think it's a critical piece of the health care agenda that we are missing and a tremendous opportunity to address huge problems in the health care system, including waiting times and overcrowding."

The future of EHS administrative data

Our findings augment the calls for improvement in the EHS administrative databases that were issued by the Canadian Emergency Department Information System working group in 20013 and the Health Council of Canada in 2007.22 The experienced researchers we interviewed perceive a need for national Canadian EHS administrative data. Although current data quality, clinical detail and population coverage were perceived by the interviewees as weaknesses, EHS administrative databases can be improved by working with stakeholders to consider database variables to improve data quality and clinical detail and to move toward a national Canadian EHS administrative database.

Based on these findings, we recommend that key stakeholders involved in emergency services across Canada work together to develop a strategy to implement an accurate, integrated and comprehensive national Canadian EHS database. We believe that this Canadian EHS database could be developed through broad collaboration including stakeholders from emergency medicine, research, information technology, health information management, data custodians, governments and the public. We believe that the public should play a pivotal role in identifying concerns for health research and match these concerns to the EHS administrative data collected to ensure future improvements.

It remains unclear who should lead the development of a Canadian EHS database and what issues the stakeholders should address. One interviewee suggested that CIHI take the lead on the development of a Canadian EHS database. Other possibilities include the federal government, the provincial governments, or researchers funded either through the Canadian Health Services Research Foundation or the Canadian Institutes of Health Research. Issues to be addressed in addition to the weaknesses we have identified include funding and training in EHS research. Web-based hubs or satellite research programs responsible for training emergency health services researchers could also be considered.

Limitations

Our study was strengthened by interviewing researchers who have considerable experience using EHS administrative databases. However, we caution that only 4 interviews were conducted and the resulting generalizability of these individuals' experiences may be limited. Further research is required with a larger sample. In addition, similar studies detailing the perceptions of other stakeholders, including administrators, end-users and politicians, would be important.

Conclusion

The 5 themes that emerged from this study all serve to reinforce the call of the Health Council of Canada for national data on emergency services, which could be readily captured through a national EHS administrative database. We feel that key stakeholders involved in emergency services across Canada should work together to develop a strategy to implement an accurate, clinically detailed, integrated and comprehensive national EHS database.

References

1. Rowe BH, Bond K, Ospina M, et al. Data collection on patients in emergency departments in Canada. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2006.
2. Spasoff RA. Epidemiologic methods for health policy. New York (NY): Oxford University Press; 1999.
3. Innes G, Murray M, Grafstein E; Canadian Emergency Department Information System (CEDIS) Working Group. A consensus-based process to define standard national data elements for a Canadian emergency department information system. CJEM 2001;4:277-84.
4. Stanford RH, Shen Y, McLaughlin T. Cost of chronic obstructive pulmonary disease in the emergency department and hospital: an analysis of administrative data from 218 US hospitals. Treat Respir Med 2006;5:343-9.
5. Lee TA, Fuhlbrigge AL, Sullivan SD, et al. Agreement between caregiver reported healthcare utilization and administrative data for children with asthma. J Asthma 2007;44:189-94.
6. Han JH, Zhou C, France DJ, et al. The effect of emergency department expansion on emergency department overcrowding. Acad Emerg Med 2007;14:338-43.
7. Macpherson AK, Schull MJ. Penetrating trauma in Ontario emergency departments: a population-based study. CJEM 2007;9:16-20.
8. DuBard CA, Massing MW. Trends in emergency Medicaid expenditures for recent and undocumented immigrants. JAMA 2007;297:1085-92.
9. Chan B, Schull M, Schultz S. Emergency department services in Ontario. Toronto (ON): Institute for Clinical Evaluative Sciences; 2001.
10. MacPherson A, Schull M, Manuel D, et al. Injuries in Ontario. Toronto (ON): Institute for Clinical Evaluative Sciences; 2005.
11. Kim S, Clark S, Camargo CA Jr. Mortality after an emergency department visit for exacerbation of chronic obstructive pulmonary disease. COPD 2006;3:75-81.
12. Sullivan G, Han X, Moore S, et al. Disparities in hospitalization for diabetes among persons with and without co-occurring mental disorders. Psychiatr Serv 2006;57:1126-31.
13. Guttmann A, Razzaq A, Lindsay P, et al. Development of measures of the quality of emergency department care for children using a structured panel process. Pediatrics 2006;118:114-23.
14. Wyer PC, Brown MD, Newman DH, et al. Evidence, values, communication: essential ingredients of shared emergency medicine decisionmaking. Ann Emerg Med 2007;49:690-2.
15. Zed PJ, Rowe BH, Loewen PS. bu-Laban RB. Systematic reviews in emergency medicine: Part II. Critical appraisal of review quality, data synthesis and result interpretation. CJEM 2003;5:406-11.
16. Zed PJ, Rowe BH, Loewen PS. bu-Laban RB. Systematic reviews in emergency medicine: Part I. Background and general principles for locating and critically appraising reviews. CJEM 2003;5:331-5.
17. Colman I, Yiannakoulias N, Schopflocher D, et al. Population-based study of medically treated self-inflicted injuries. CJEM 2004;6:313-20.
18. Worster A, Rowe BH, Stiell IG, et al. Clinical research in the emergency department conducted by non-emergency physicians: potential problems and proposed recommendations. CJEM 2005;7:241-8.
19. Rowe BH, Brown MD. A primer on the Cochrane Collaboration, its new priorities in out-of-hospital and emergency health, and the role of Annals of Emergency Medicine. Ann Emerg Med 2007;49:351-4.
20. Rowe BH, Bond K, Ospina MB, et al. Data collection on patients in emergency departments in Canada. CJEM 2006;8:417-24.
21. Merton RK, Lowenthal MF, Kendall PL. The focused interview: a manual of problems and procedures. Glencoe (IL): Free Press; 1956.
22. The Health Council of Canada. Health care renewal in Canada: Measuring up? Toronto (ON): The Council; 2007.