In San Francisco, the “most costly user of publicly financed emergency health services…a ‘frequent flyer’ in emergency room parlance – is 49, Caucasian, schizophrenic, and addicted,” writes R. Jan Gurley, a board-certified internist who treats many homeless patients in that city and pens a blog titled “Doc Gurley: Posts from an Insane Healthcare System.”

Gurley continues; “He has been listed in at least two concurrent city systems as homeless (either continuously or episodically) for 16.6 years. He’s a frequent caller of ambulances (more than four times a month), a frequent user of detox and sobering center services, and a high utilizer of mental health services (including psych emergency). He is very, very ill.”

He is also costly to the public health care system. According to Gurley, last year the homeless man with this dubious honor “used an estimated $155,453 worth of emergency and urgent services alone (not counting other medical costs)” despite having a legal conservator and being enrolled in the city’s Department of Public Health intensive case management program.

Identifying this most frequent of fliers is just one of the results of an innovative information technology system designed by a small team at San Francisco’s health department who wanted to “figure out how to track, and help, those people who are failing (and being failed by) our public health safety net systems,” writes Gurley.

It turns out that in most communities—whether they are large cities like San Francisco or New York or smaller towns and counties across the nation—each seperate safety-net provider or agency that deals with mental health, substance abuse, emergency care, housing, etc., maintains its own client database. These systems are rarely connected.  Gurley writes;

“In our rush to buy and develop electronic platforms, every agency has its own database — an incompatibility problem that becomes more complex the more people served. The data system for ambulances doesn’t talk to the data system for shelters and housing, which doesn’t talk to the data system for elder services, which doesn’t talk to the mental health system, or the substance abuse system or the medical system or the jail system or… You get the picture.”

In San Francisco, the team, led by Maria X. Martinez, Deputy Director of Community Programs at the Department of Public Health set out to unify this poorly coordinated system. “The brilliance of their approach was to take isolated silos of data and merge them together. No employee had to change how he worked or modify a database. All they had to do was dump their data to a central digital safety-net warehouse.”

After creating this central repository for all safety net data, Martinez decided to look for individuals who were “high utilizers across multiple systems” or HUMS.  What she found, writes Gurley, “is a whole population of people suffering, dying, and using safety net services in extraordinarily inefficient and high-cost ways.

“And they are almost all homeless.”

Here then, are some stark facts that emerged from the central data repository for safety-net programs, taken from Gurley’s post:

•    The HUMS database, as of February 2, 2011, contains 227,223 people, with data going back as far as 1992.

•    Of those 227,223 people, 18 percent (50,266 ) have at some point been listed as homeless by two or more different systems. Of the people who received services last year, 6 percent (16,494) were listed as homeless by two or more data systems during 2009-2010.

•    High utilizers of ambulance services are defined as having used an ambulance more than four times a month. Collectively, this subgroup racked up 3,093 transports, 74 percent of them for sobering center clients.

•    In 2009-2010, 477 people were ranked as HUMS, and they used $20 million worth of urgent/emergency services — an average of $42,067 each. The top 100 used $8.1 million worth of urgent/emergency services alone in that year.

•    The average age was 47.8, 75 percent were male, 92 percent spoke English, 49 percent were Caucasian, 29 percent were African American, and 12 percent were Latino.

•    Thirty nine percent were high utilizers of ambulance services, 77 percent had used urgent/emergency substance abuse services, and 75 percent had used urgent/emergency mental health services (like psychiatric EDs).

•    Twenty seven percent had a diagnosis of schizophrenia, and 15 percent had had legal conservators at some point. Sixteen percent were HIV-infected, and 42 percent had hepatitis C.

Gurley commends Martinez and her group for being brave enough to set out and try to find and define the high utilizers of multiple systems.  As she puts it; “There is an old saying in medical training: ‘Don’t ask the question if you don’t want to know the answer.’” As employees of a city public health agency, “once they had a result, they were going to be asked to deal with it, however difficult that may be. And because they designed a method for seeing what happens, they can’t hide whether they’re failing or succeeding, either.”

Clearly, using a centralized health information exchange to identify who the “HUMS” are in any community is only the first step in reducing the suffering of these folks and in addressing the costly and inefficient use of safety net services. I think everyone agrees that something is seriously wrong with a safety net system when patients arrive by ambulance to the emergency room drunk or over-dosing four times in one month.

But what will San Francisco and other communities who are choosing to create “health information exchanges” and other unified data systems to better understand and serve their safety net populations do with this information? As Gurley points out, people who use a lot of safety-net services—especially the homeless—can seem very difficult to help. The homeless man who racked upwards of $155,000 in emergency and urgent services last year did have a case manager and was enrolled in a program meant to steer people like him to a range of health and social services. But he likely never showed up to his scheduled appointments. It is easy for the most vulnerable to disappear: they have no telephone, no address, and no calendar or “even a regular spot on the sidewalk.” Even with a centralized health record it can be impossible to provide consistent treatment or track progress.

The question of what actions to take next is a tough one. Urban communities around the country are studying or designing similar integrated systems—taking advantage of federal funding available for “meaningful use” of health information technology. In King County, WA, (which includes Seattle), for example, there are about 227,000 adults in the safety-net population. A fair number are veterans, many have psychiatric disorders and most are chronically ill. Total expenditures for the “safety-net population,” according to a recent business plan developed by the Partnership for Health Improvement through Shared Information (PHISI)—a consortium of health care providers and other public stakeholders in the county—was $715 million last year. The authors of the plan estimate that if a unified health information exchange was used by all Medicaid and other safety net providers, the county could save up to $38 million of that.

How will these savings be wrought?

The PHISI business plan cites medication coordination—doctors at an emergency room at one hospital will be able to access information about previous medication and care given to a patient at other facilities. This avoids duplication of tests and helps maintain a standard treatment. A medical home, at a community health center or safety-net hospital that helps coordinate all the services accessed by a given individual; substance abuse treatment, mental health care, medical care and housing, could help reduce utilization and improve the prognosis of those hard-to-treat patients. In an interview with MedCity News about how to reach the homeless and addicted—the toughest of the safety-net population who cycle in and out of emergency departments, hospitals and jails—Gurley says for these folks, “the only key to success lies in making a real human connection with someone ‘outside;” a drug counselor, nurse, therapist or other practitioner. She talks about visiting a local needle exchange and finding a safe place where addicts (many homeless) can go to make a regular connection with someone that could have the power to draw them back from the brink.

There are no easy answers. This post began by describing a technology platform that can provide important insights into the largest consumers of safety-net services; the portion of the population that accounts for an inordinate amount of government spending. This technology— uniting disparate sources of data to create a single, highly coordinated health information exchange—will be very valuable in identifying and defining where the problems begin. But any solutions to these problems will require a new (and in these times of budget cutting, perhaps unlikely) dedication to strengthening a safety net that is increasingly being stretched to the breaking point.