The Emergency Department as “The Room with a View" of Health Reform of the Past, Pesent, and Future of Our Health System

The ER is more than a hospital department. It’s a “room with a view" of the health system.

Arthur L. Kellermann, MD, and Ricardo Martine. "The ER, 50 Years On,” New England Journal of Medicine, June 16, 2011

In a June 16 NEJM issue, A.J. Kellermann,MD. and Ricardo Martinez, MD, of the RAND corporation and Emory University Department of Emergency Medicine, discuss the state of emergency room care over the last 50 years.

With the ER, they conclude , some things:

• have remained the same – the hospital admission rate from the ER remains 16%;

• the growth rate remains rapid at twice the rate of the population growth;

• the reasons for growth remain the same – hospitals must accept all comers; you can always get care in the ER at all times; doctors are performing more procedures in ER rather than offices; doctors are unavailable in off-hours and weekends;

• care is more complex and technologies has changed because of aging patients, new imaging and other diagnostic techniques, and more effective methods of resuscitation.

• burdens of caring for acutely ill, uninsured, and children have grown disproportionately.

More than anything else, the ER is “room with a view” of the health system – its gaps, the state of public health, the lack of primary care physicians.

The authors offer two views of the future;

• One driven by deteriorating access to care, unavailable primary care physicians, and unaffordable specialists.

• The other centered on patient needs, not convenience of providers, free flow of information from home, to office, to ER, the right care at the right time at the right place.

In a accompanying article, “The Waits That Matter,” John Maa, MD, a San Francisco surgeon, argues that the first option is unacceptable because it produces long wait times, during which patients may die, as his mother did.