The Emergency Room: Managing The Gateway to Higher Costs

It is by presence of mind in untried emergencies that the native metal of a man is tested.

James Russell Lowell (1819-1902), Abraham Lincoln (1864)

October 8, 2012 – Emergency room use poses a seemingly unsolvable problem for the U.S. health system. By law, ERs are open 24 hours a day to all comers. By definition, ER visits are more expensive than office or clinic visits.  ERs are cost losers to hospitals.  ERs are the only place to go when you are sick and your doctor’s office is closed.   ERs are invariably crowded.  Being seen in ERs usually takes hours.  When health reform opens the floodgates of care, as in Massachusetts, ERs became even more congested.  Many Medicare and Medicaid recipients go to ERs  even when insured.   

As the following  October 5 article from Kaiser Health News shows,  ER visits can be avoided.  And as this past post of mine demonstrates, innovation can lower wait times.

Study: Most Seniors’ ER Visits Could Be Avoided

By Phil Galewitz. October 5, Kaiser Health News

Nearly 60 percent of Medicare beneficiary visits to emergency rooms and 25 percent of their hospital admissions were “potentially preventable”– had patients received better care at home or in outpatient settings — according to results of a study released Friday by a congressional advisory board.

“These are spectacular rates,” said Scott Armstrong, a member of the Medicare Payment Advisory Commission and CEO of Group Health Cooperative, a Seattle-based health plan.

The commission’s preliminary study, released at their monthly meeting, found the most common diagnosis for preventable ER visits was upper respiratory infections. The most common diagnosis for preventable hospital admissions was congestive heart failure.

The potentially preventable admissions or ER visits do not indicate the hospital acted inappropriately. Instead, they are a measure of a community’s outpatient care system that includes private physician offices, community health centers and urgent care centers, study co-author Nancy Ray, a MedPAC principal policy analyst, told commissioners. Ray said not every preventable ER visit or admission can be avoided. The study showed wide variation of these rates across the country and within cities.

Patients could avoid preventable ER visits by having health conditions treated by family doctors or urgent care centers or by making sure to take all their medicine. Hospital admissions could be prevented if conditions such as asthma, diabetes or heart failure were better monitored by patients and their doctors, commission staff said.

The study analyzed health services provided to 5 percent of all traditional Medicare program beneficiaries from 2006 to 2008. It also looked at care provided to all Medicare beneficiaries in six markets: Boston, Phoenix, Miami, Minneapolis, Greenville, S.C., and Orange County, Calif. MedPAC officials said it would release marketplace details when the report is completed in a few months.

The study found hospitals that had lower occupancy rates had higher rates of preventable ER visits and admissions. Medicare beneficiaries who also receive Medicaid— a category known as “dual eligibles” — also had higher rates.

Researchers have been looking at reducing preventable ER visits and hospital admissions for years, though this is one of the first large analyses of Medicare patients. Hospitals in 2006 spent $30.8 billion on 4.4 million hospital admissions that might have been avoidable, according to a report by the federal Agency for Healthcare Research and Quality. A 2006 Rutgers University study found 47 percent of ER visits in New Jersey were potentially avoidable.

Clinical Innovation in the Emergency Room- Managing Complexity at Ground Zeor, February 17, 2007, Medinnovation Blog

I’e just finished a phone conversation with Wesley Curry, MD, president of California Emergency Physicians (CEP.com) for the last ten years. The California Emergency Physicians’ organization has existed for 35 years, recently changed its name to CEP, and is expanding outside of California.

CEP covers 62 emergency departments in four states, has 1100 participating physicians, physician assistants and nurse practitioners, who provide care to 2.5 million patients each year. CEP is the largest democratic emergency medical group in the United States. I italicize democratic because Dr. Curry considers the word a badge of honor. It implies “one man, one vote” in terms of governance of the partnership and indicates CEP has broad physician ownership (no physician owns more than 0.5% of partnership assets) and therefore CEP is truly physician led and free of outside investor or corporate influences.

Doctor Curry’s views on innovation in emergency room settings are refreshing. He foresees more efficient and more humane emergency room services will require intelligent physician leadership, creating teams of physician -nurse leaders, delegating emergency department design and function to the professionals who provide patient care in the emergency department and who work there.

“Our distinctive competence is managing physician practice complexity and implementing innovations in simplicity. We improve the patient throughput process in the emergency department of our client hospitals, with the express purpose of seeing both low and high acuity patients in a rapid manner. We strive to minimize the time it takes for a health care provider to see the patient from time of arrival, thereby creating more face time for physicians and nurses with patients."

“Unlike the traditional triage methodology used by most emergency departments for years, we use a provider up front, or provider at triage, to move closer to the entry point of low acuity patients, to evaluate and discharge them in such an efficient manner that they are in the emergency department for a very short time, and often are never put into a treatment room.”

“The overall impact on the emergency department operations is dramatic, with significant reductions in important metrics of performance, such as time to provider and length of stay in the emergency department.”

Curry says a central problem leading to current emergency department inefficiency is that “everybody” – meaning hospital administrators, in-house specialists, other hospital departments, and payers – in the past have determined their own procedures and policies regarding patients in the emergency department. This procedural and policy fragmentation slows patient throughput the care process in our practice environment, essentially slicing patient encounters into multiple components over which we have had little control until now.

This “slicing” of the patient encounter to meet the reimbursement, documentation, availability, and work product delivery preferences of other areas or departments in the hospital, as well as the requirement of all the internal hospital and external government, and insurance company “stakeholders, ” has caused paperwork to explode during my 25 years in emergency medicine. There now is a “slice” of paper for every stakeholder, overseer, and for every perceived purpose of others who do not get face to face with the patient.

“When I started,” Curry comments, “We had one piece of paper per patient for nurse and physician documentation and orders. Now we have a paper blizzard, with perhaps 30 pages or more generated for each patient seen in the emergency department.”

Much of this paper blizzard is dedicated to creating a medical record for people “at the back end” – the hospital, the payer, and in some cases, the lawyer -- rather than expediting care at the “front end” – when patients meet and experience face time with the health care provider (physicians, nurse practitioners, and physician assistants).

The number of individual pieces of papers in the patient’s medical record proliferate with demands for documentation of every aspect of the patient encounter. This distracts from paying attention from what ought to be the true objective, more time for face-to-face doctor-patient interaction and encounter.

Dr. Curry estimates emergency room physicians and providers may spend as little as 30% of their time in front of patients, and the rest dealing with the paperwork and communications with others to resolve aftercare and disposition issues.

He doesn’t see software and information technology as the answer either. He observes, “The ED doctor spends what seems like 2-3 hours each workday logging in, inputting or requesting information and logging out of 6 to 8 software programs that now have become mandatory to use in the patient encounter. One proprietary program may be for obtaining lab results, one for x-ray, one for discharge, one for recalling past charts, and so forth – and each one log-in log-out requires more time for getting through the various security screens which shut down the program if there is no activity after a few minutes, when the provider is away from the computer seeing patients.

He continues, “This logging takes at least 30 seconds to one minute for each program, and in aggregate takes a significant amount of time which could be used to see patients. These programs help retrieve past medical records, and other useful information and document the encounter, but, he asserts, “They have much less value in creating real time efficiency.” Proliferating independent proprietary electronic medical records and other software programs, he adds, “are simply not there yet.”

Dr. Curry sums up his position, “I believe it all boils down to the local physician leadership, coupled with nursing leadership, and hospital senior administrative support, to make an emergency department an efficient place to see our ever growing numbers in patients seen each year.”

“At CEP our goal has been to educate hospital administrators about the whole process, of getting patients seen, evaluated, and admitted to the hospital or discharged home efficiently. We must do this as physician-nurse teams able to lead the process of change in an ever more complex practice environment.”

“We must teach hospitals and other stakeholders about the ‘best practices’ found in our client hospitals, and the enormous impact on the hospital’s bottom line when the emergency department runs smoothly and efficiently, prevent other stakeholders in the patient encounter from torpedoing ED efficiency either on purpose to suit their own needs or inadvertently from a lack of knowledge or their own inefficiencies-- from keeping us from doing what needs to be done – spending time seeing patients.”

He concludes, “To accomplish our mission, we need to serve as mentors for administrators and other decision makers to keep them informed about them what’s taking place at ground zero in the emergency department.”

He gives three examples of what can be done. These examples show the need for commonsensical simplicity to overcome nonsensical complexity. This complexity accounts for what plugs up the ER and creates as bottleneck for efficient care.

• First, he says the use of “smart charts, “ consisting of a paper based medical record and series of check-off boxes and hand written entries, enormously speeds up chart creation and documentation process for low acuity patients in the emergency departments with high patient volumes.

• Second, he cites use of “scribes,” non- professionals with some medical and technical training to “shadow” the health care provider and help document the patient encounter and assist in the creation of medical record and disposition paperwork. Scribes save doctors a great deal of dictating and chart-making time. Doctors may still need to dictate the record for complex patients, but not for patients with minor problems.

• Third, Dr. Curry describes CEP’s Rapid Evaluation Program, where the initial concept was conceived developed by a CEP medical director a number of years ago. Over time this program has been redesigned and improved, and is now being implemented in most of the high patient volume sites in CEP. Using this technique, CEP has cut waiting times from 3 to 4 hours to in many emergency departments to just about 30 minutes on average, and sometimes to as little as 10 minutes.

CEP’s Rapid Medical Evalution Program has received national attention as a proven way to decrease patient waiting times in emergency departments of any type, including large public and teaching hospitals. The RME Program, started in 2002, changes how patients are treated.. Under RME, the treatment process is fluid. It adjusts, based on demand and resource availability, to ensure treatment is provided as fast as possible.

The treatment process begins immediately, including an initial assessment, ordering of labs and X-rays, and in some cases, rapid discharge without using an emergency department bed. When beds are available, patients are placed immediately in a bed and examined by a physician.

The RME approach has positively impacted CEP’s emergency departments. Every CEP emergency facility using RME has substantially cut time to see doctors , with site reductions ranging from 10-80 minutes. RME has slashed numbers of patients leaving without being seen. Patient satisfaction has climbed across CEP sites, and many CEP practice locations are ranked in the top 10% of similar sites nationwide.

RME has resulted in greater revenues for both hospital and emergency department physicians. These improvements have occurred regardless of size, payer mix, and geographic layout of emergency department, including large sites, urban sites, small emergency department with large populations, and rural emergency units.

What impressed me about Dr. Curry is that he intuitively understands innovation fundamentals. According to Peter F. Drucker, the father of modern management theory, every organization must follow four principles of innovation:

• abandon what doesn’t work (the old way of seeing emergency room patients didn’t work);

• take steps to improve (smart charts, scribes, rapid medical evaluation);

• exploit successes (grow nationally with RME system and democratic physician relationship philosophy);

• organize for systematic innovation ( Dr. Curry, although he doesn’t have the title, is CEP’s Chief Innovation Officer, and has assembled a team of like-minded MDs to carry out the mission).

Dr. Curry understood changing “process need” was an important window of innovative opportunity. Everybody knew “something was wrong” with the “process” of seeing patients. It was “obvious” long wait times, clogged EDs, unhappy patients, and even dangers to the health of waiting patients, was not “right.”

What Curry and colleagues did was innovate to provide the missing link – lack of patient face time – and to act upon that knowledge by defining the missing link (lack of physician and nursing leadership), delineating specifically how to solve the process problem (smart charts, scribes, REM, mentoring administrators), stating the objective (shorter wait times), and broadcasting the message that there had to be a better way.

The result of CEP’s innovatively addressing “process need” is that CEP’s approach has become “obvious” and is now being increasingly adopted as a new “best practice” and has the potential to become a national standard in the operations of emergency departments everywhere.

Many effective innovations for bettering the health system begin from the “bottom-up,” from people working in the clinical trenches and dealing with issues on the ground, rather than from well-meaning external or top-down managers and technology experts, who assume they know what’s wrong and how to fix it, but who have never been there and done that.

Doctor Curry says productivity solutions are often either “low-tech” or even “no-tech” and flow from individual seekers of efficiency rather than from system tweakers outside care sites. Answers to productivity problems, Dr. Curry observes, may reside in the mundane rather than the arcane.

Tweet:   Half of ER visits can be prevented; and long waits could be reduced by simple steps – doctors at front end, smart charts, and scribes.