Successful disease management in a community sharing health information through an exchange

Background Low income and uninsured populations bear a disproportionate burden of chronic disease. Central Texas region has one of the highest rates of uninsured populations in the country (estimated 24%). Health information technology provides communities the opportunity to assist the underserved and uninsured populations through innovative solutions to fragmented care.

Objectives To evaluate a disease management program that uses a health information exchange (HIE) database to identify uninsured patients and enroll them in an asthma education and self-management program.

Methods Uninsured patients with ≥1 emergency department or inpatient visit or ≥4 clinic visits with an asthma-related diagnosis (ICD-9 codes 493.*) in the last year are identified through the HIE. A certified respiratory therapist contacts the patients to arrange a home visit that includes education on self-management of the disease, helping with eligibility for medical assistance programs, and appointment with a primary care physician. Data on emergency and hospital use are collected from the HIE database and quality of life measures through patient surveys pre- and post-enrollment.

Results During the first year of the program, 172 patients were enrolled in the program. 64% of patients were Latino, 19% African American, and 16% White. More than half were under 18. Enrolled patients showed fewer emergency visits (p<0.01), less hospitalizations (p<0.01) and improved quality of life measures (p<0.5) in the one year after the program.

Conclusion The asthma disease management program is a successful demonstration of how communities can use HIE data to provide focused public health interventions to uninsured and underserved populations.