A Comprehensive View of Frequent Emergency Department Users Based on Data From a Regional HIE

Steven Howard Saef, MD, MSCR; Christine Marie Carr, MD; Jeffrey S. Bush, MD; Marc T. Bartman, MD; Adam B. Sendor, BA; Wenle Zhao, PhD; Zemin Su, MS; Jingwen Zhang, MS; Justin Marsden, BS; J. Christophe Arnaud, BS, Cathy L. Melvin, PhD, Leslie Lenert, MD, MS, William P. Moran, MD, MS, Patrick D. Mauldin, PhD, and Jihad S. Obeid, MD


South Med J. 2016;109(7):434-439. 

In This Article

Abstract and Introduction


Objectives: A small but significant number of patients make frequent emergency department (ED) visits to multiple EDs within a region. We have a unique health information exchange (HIE) that includes every ED encounter in all hospital systems in our region. Using our HIE we were able to characterize all frequent ED users in our region, regardless of hospital visited or payer class. The objective of our study was to use data from an HIE to characterize patients in a region who are frequent ED users (FEDUs).

Methods: We constructed a database from a cohort of adult patients (18 years old or older) with information in a regional HIE for a 1-year period beginning in April 2012. Patients were defined as FEDUs (those who made four or more visits during the study period) and non-FEDUs (those who made fewer than four ED visits during the study period). Predictor variables included age, race, sex, payer class, county of residence, and International Classification of Diseases, Ninth Revision codes. Bivariate (χ2) and multivariate (logistic regression) analyses were performed to determine associations between predictor variables and the outcome of being a FEDU.

Results: The database contained 127,672 patients, 12,293 (9.6%) of whom were FEDUs. Logistic regression showed the following patient characteristics to be significantly associated with the outcome of being a FEDU: age 35 to 44 years; African American race; Medicaid, Medicare, and dual-pay payer class; and International Classification of Diseases, Ninth Revision codes 630 to 679 (complications of pregnancy, childbirth, and puerperium), 780 to 799 (ill-defined conditions), 280 to 289 (diseases of the blood), 290–319 (mental disorders), 680 to 709 (diseases of the skin and subcutaneous tissue), 710 to 739 (musculoskeletal and connective tissue disease), 460 to 519 (respiratory disease), and 520 to 579 (digestive disease). No significant differences were noted between men and women.

Conclusions: Data from an HIE can be used to describe all of the patients within a region who are FEDUs, regardless of the hospital system they visited. This information can be used to focus care coordination efforts and link appropriate patients to a medical home. Future studies can be designed to learn the reasons why patients become FEDUs, and interventions can be developed to address deficiencies in health care that result in frequent ED visits.


People in the United States visit emergency departments (EDs) more than 136 million times per year, and up to 28% of visits in certain areas have been made by frequent ED users (FEDUs).[1–3] The definition of a FEDU varies from study to study; for the purposes of this study we accepted the criterion of four or more ED visits per year.[4,5] There is a consensus that FEDUs tend to have more substantial health problems, increased mortality, more chronic conditions, and more mental health issues.[4–17] Health information exchange (HIE) has provided the first opportunity to describe FEDUs by assembling data from patients visiting all EDs within a region.

Notifying busy emergency physicians about FEDUs can inform them when it is worthwhile to query the HIE, avoiding unnecessary logons. Use of an HIE in the ED has been shown to reduce healthcare spending and time spent by healthcare providers per patient without changing treatment outcomes by eliminating or reducing duplicate testing, decreasing lengths of stay, and helping to address overcrowding in the ED.[8,18–20]

Improving accommodations for FEDUs may address their episodic, fragmented patterns of health care and transition them from an ED-based medical home to one that provides the benefits of a primary care provider.[16] The ED is not poised to offer the benefits of primary care as espoused by the Framingham Heart Study and a large Department of Veterans Affairs cooperative study.[21,22] Transfer to a medical home designed to provide longitudinal care could improve patients' health by addressing cardiovascular risk factors and screening for cancer.

In this study, we used data from an HIE to describe all ED patients in the region of a mid-sized southeastern US city during a 1-year period beginning in April 2012. Our dataset was comprehensive and had two advantages over the use of data from a single ED. First, every ED in our region participated in the HIE during the study period. Second, we had an "opt-out" method of registration for our HIE, which meant that unless the patient declined participation at the time of registration, he or she was included. This led to a much greater enrollment than an "opt-in" methodology, which requires patients to provide separate consent to be included in the HIE.[23] In an opt-in situation participation tends to drop precipitously. No one opted out of our HIE during the study period, making it a comprehensive dataset that included every patient who visited an ED in our region during the study period. We are not aware of another HIE with such a complete dataset. We must acknowledge, however, the possibility that some patients accepted the HIE without reading the "fine print" during the registration process. This is because all four disparate hospital systems that participated in the HIE, including 11 separate EDs, reported 100% enrollment; therefore, we believe the dominant reason was that the HIE was presented in a positive manner and that patients considered the idea of HIE to be a positive one and a natural, expected next step in the evolution of electronic medical records. Furthermore, all of the patients were recorded using the same methodology, so there was no change in content when comparing and combining data from different EDs. We used this information to define the parameters that made someone more likely to be a FEDU than a non-FEDU and compared our findings with published reports. The comprehensiveness of our dataset is especially important given previous work that showed that FEDUs visited different EDs within a region to a greater extent than non-FEDUs.[6]

Finally, we investigated whether certain designations from the International Classification of Diseases, Ninth Edition (ICD-9) were independently associated with being FEDUs. This allowed us to identify new directions of study to better characterize FEDUs and in the future will allow us to develop ways to better meet the needs of these patients.