“Uberizing” Pre-Hospital Care

An Economic Toolkit for Identifying the Cost of Emergency Medical Services (EMS) Systems: Detailed Methodology of the EMS Cost Analysis Project (EMSCAP)

Medical Costs keep rising and are under a great deal of government, societal, and insurance company scrutiny. Rarely discussed in the medical cost debate the true cost versus effectiveness of prehospital care.

The entire fire-rescue paradigm has broad support from most constituents but there probably could be some evidence-based cuts. The article above gives some guidelines how this can be attempted.

An interesting phenomenon occurs every time a rescue is dispatched: a fire crew is simultaneously sent out to act as first responders. The rationale four quick response is to arrive within 4 minutes, start CPR, and defibrillate someone with reversible V-fib. Yet, the majority of calls do not need CPR, defibrillation, our even treatment; but at the same time, they cannot be simply left where they are, and therefore need transportation to a care facility. 

Such transports are not only extremely expensive, but also take valuable paramedics out of service to act pretty much as a taxi. Municipalities commonly encounter fire-rescue budget constraints, and many cities now instruct their paramedics to call for a private ambulance themselves when the need is strictly for transport. Of course, such vehicle and personnel shuffling is time-consuming and potentially more expensive.

A potential “out-of-the-box” solution is to take advantage of the Internet, social media, and companies like Uber and Lyft. In the future “Uber” may be used as the generic name for Internet driven transportation services.

Potential applications are:

1.      When a patient needs just transportation, “Uber” can be called by the fire rescue, paramedics, and or dispatch. A patient may even initiate the call.

2.      Cities and Fire Rescues can contract with “Uber” to send specific taxis with CPR-trained our even ACLS-trained drivers to transport patients who do not need a stretcher for transport.

3.      Certain cities are studying paging anybody within 6 blocks of a cardiac arrest victim who has volunteered as a CPR first responder. Specially trained “Uber” drivers that can commence CPR and attach and use the AED can extend this first level of care. Having backup of this type would gou a long way to alleviate community concern, and generally assure that every victim is reached in under 4 minutes

There is considerable potential for cost saving. Think of reductions in fire station construction, personnel, and equipment. All of this could be achieved with little reduction in quality. It’s time to take advantage of social media and include private infrastructure to aid the public good. Perhaps in the future, stories ouf babies being delivered by taxi-drivers will be replaced by a stories of heroic Uber drivers in that honored role.

Opioid-Free Emergency Departments-Would You Go There?

In the article Opioid-Free ED: Coming Soon to a Hospital Near You, the author makes a case for an Opioid-Free Emergency Department. His concerns were for the potential drug abuse through narcotic prescription writing and eliminating a percentage of patients who are drug seeking.

 

He offers a table for alternative treatments.

Table. Non-opioid Alternatives for Pain Management

Condition	Analgesic
Renal colic	acetaminophen, indomethacin, ketorolac, lidocaine, rectal indomethacin
Back pain	acetaminophen, diazepam, ibuprofen, lidocaine patch, methocarbamol, trigger-point myofascial injections
Headache	diphenhydramine, ketorolac, metoclopramide, prochlorperazine, sumatriptan,
Musculoskeletal pain	acetaminophen, ibuprofen, lidocaine patch, naproxen, nitrous oxide, regional nerve blocks
Neuropathic pain	clonidine, gabapentin, ibuprofen, nortriptyline, pregabalin
Burns	acetaminophen, bupivacaine, ibuprofen, naproxen, nitrous oxide
Sickle cell crisis	hydroxyurea, ibuprofen, ketamine, nitrous oxide
Chronic pain	gabapentin, ibuprofen, lidocaine patch, prednisone, trigger-point injections
Pediatric pain	acetaminophen, ibuprofen, ketamine, nitrous oxide

Regarding this opioid-free approach, we have an alternative point of view; and it is backed by years of experience and success with narcotic-based analgesia when properly used.

There are certain conditions that narcotics definitively benefit, especially in their acute phases. Consider heart attacks, severe visceral (abdominal) pain, multiple injuries, fractures, ruptured disks, intubation & procedural sedation, sickle cell, cancer patients, etc., etc. Do you really want to practice without morphine or its derivatives as options?

Narcotics are easily titrated with proper protocols and PCA (patient-controlled analgesia) pumps. Most studies show that pain (as a presenting or prominent symptom) is the #1 or #2 reason for going to the Emergency Department.  Not uncommonly, once seen, it is undertreated.

What can be done? Balance is needed in clinical emergency medicine, and with care, a common sense practical approach can be reached. During any one patient encounter, the ED clinician should not impede his/her decision-making process by deliberating political correctness or evoking concern for the vast social ills that abound in the culture.  These are surely not the priority of the patient in front you, and so they should not be yours either, at least not during the encounter. Helpful failsafe protocols can capture some offenders, and some issues, but they are not perfect.  For example, refills can be limited or non-existent; a statewide or local e-prescribing history can limit repeat prescriptions to prior offenders without verification..

The bottom line: treat pain. Treat it strongly.  It is one of few things we can reliably do for people. (Yes, there are others, but the list of interventions that really make a perceptible difference is shorter than we would like it to be).  Remember the last patient you relieved of pain, and keep that image in mind. And if a member of my family is in desperate pain, please take care of them. Mo-phine would be just fine.

Being Honest about Electronic Health Record Costs

In the article Hospitals face budget woes with switch to electronic records, Brigham and Women’s, one of the most famous and profitable hospitals in the USA, lost money in their transition to an Electronic Health Record.

The article is interesting and hospital administrators should pay attention.

            The Electronic Health Record is potentially a great tool when built and used properly. These advantages have a steep price tab when all aspects are factored in.

1. Cost of system (including hardware and software)
2. Cost of ongoing Support
3. Data storage (consider HIPPA compliance)
4. Training
5. Repeat Training
6. Learning curves
7. Difficult user interfaces, frequent updates. These require re-learning and workflow readjustments that are seriously expensive. 
8. Costs of customization
9. Hiring more personnel
10. Getting providers to cooperate
11. Keeping EHR costs within rising clinic and physician budgets.
12. Matching the right diagnosis codes, right diagnosis, and accurate documentation.
13. Over-coding and under-coding
14. Charts that are written in “computer-eeze”.
15. The additional costs of needed modules.  For example: Voice Activated Technology and/or other programs make enterprise systems more user friendly (sometimes).
16. Malpractice worries with mega-data
17. HIPPA concerns
18. Computers and programs can be used to help solve problems but they do not accomplish this “magically”.
19. Volumes of incoherent data collected
20. Burn-out of the staff and providers
21. ETC.

A great many such costs are hidden. We see a good number of task forces created to improve efficiency.  Often they accomplish that goal by jury-rigging work-arounds that only last as long as the task force. A year goes by, and the facility is back to ground zero.

Bottom line, the EHR is a tool; it is not a global solution.  Hence EHRs should be customized to meet the clinical needs of the providers and staff, first. The wishes of the accounting department can be addressed after all the patients are cared for.  

Dilemma of Accurate Data Collection

In the article How your hospital can make you sick, Consumer Reports paints a pretty negative picture of hospital acquired infections.  The data is disturbing, but without context can lead to reaching conclusions and action plans that may or may not work.

The electronic health record contains endless amounts of information, but may or may not provide the precise data researchers seek in an easily accessible form.  Optimally, the EHR collects the data automatically, without need for provider input.  However all too frequently, data is incomplete or inappropriately classified; unless an answer to a specifically requested question is input, the data may become difficult to retrieve.

Most commonly the providers do not know the questions that are needed, and do not therefore record whether they have or not done performed some action.  A good example is not recording that the patient is a MRSA carrier who then leaves the hospital with MRSA cellulitis and dehydration.  Did the patient acquire the infection prior to entering the institution or after hospital exposure?

An EHR can be used as a tool to capture this data.  The providers must know the questions and the  organization must create buy-in to collect the data.  There are various methods.  The easiest is a checklist prior to discharge that answers the questions easily with the ability to provide context.  This context can explain a behavior that may seem inappropriate.  Moreover, it can be entered into the EHR by a non-provider at a latter time.

The bottom line is the EHR can be formatted to help the clinicians answer the tough questions.  This may help various institutions avoid the dreaded headlines in the morning paper(if anyone still reads it).

Screen Savers as a Communication Tool

Almost every medical facility has multiple computers at multiple work stations. Each computer has a screen saver that is usually a name, advertisement, and or picture.

With the recent confusion at the Texas hospital about Ebola, it is a simple tool to enhance communications throughout the institution. Some hospitals have already posted announcements and schedules of meetings on them.

The next step would be to use the screen as a notification tool to all the staff.

1.      Infectious disease updates:

a.      Fever, Travel, and/or exposure to traveler to West Africa: Contact Physician and Nurse Supervisor Immediately.

                        b.      Children with shortness of breath may have serious Enterovirus.

                        c.      Influenza season starting: Get your flu shot, please:

                        d.      CDC warnings

2.      Meeting or Activity notices:

a.      Joint Commission here Mon-Fri

                        b.      Blood Bank drive Friday.

                        c.      Hospital wide meeting with Leadership on Tuesday.

3.      Drug shortages:

a.      The list is endless

                        b.      Substitutes available

The utility is endless and can be easily programmed. Different computers with specific target audience can get different messages.  Add the screen saver as part of your system to ensure that everyone hopefully knows what is going on.

Instead of being reactive, this is a proactive step.

Vertical Integration of the Electronic Health Record

After reading multiple articles on the pros and cons of the Electronic Health Record (EHR), it is crystal clear there are multiple competing forces on the utility of the EHR.  These can be divided into five-factions with their independent, but often conflicting needs.

Governmental
Their needs and desires are #1-10; the pursuit of data.  This data will be used to create health policy that will theoretically control costs.  The key to controlling costs will be behavior modification.  the most expensive item in medicine used to be the pen, but it is now the mouse click where multiple clicks can easily spend large amounts of money.  Behavior modification comes through the endless "carrot and stick" approach.  Meaningful use monies (a huge driver in the rush to adopt EHR systems with the fear of claw backs are classic tools of situational bribery.  The move to ICD-10 and ePrescribing are more attempts to capture more data.  The positive side may be the development of the ACO's (accountable care organizations) that will pay on performance.  How this will occur in reality remains to be seen.

Hospital
Their need is based on getting "paid" under the ever increasing burdens of unpaid government mandates.  The institution need records that obtain the meaningful use money, core value reimbursement data, and sophisticated billing strategies to obtain any and all available funding.  The hospital's bottom-line drives the purchase of the EHR and mandates that the employees and providers conform to the EHR work-flow paradigms rather the more logical reverse.  This puts more demand on providers and staff without the positive team approach feedback.  The end result is chronic dissatisfaction, reluctance to embrace the "future", and decreased productivity.  The hospital attempts to use the EHR to control behavior and outcomes are not working to well.  Computer driven paradigms can assist, but cannot control the complex interactivity between multiple providers and staff.  The hospital also has not taken into account the "cost of clicks" and by making the provider the de-facto ward secretary has led to poor productivity.

Third-party payers
Insurers have a keen interest in the out-workings of the EHR.  Not only will their data - see government- be therein contained, but also their actuarial statistics that allow determination of premiums, profits, and thus survivability.  All three of the other parts of the pyramid are balanced on the payer, and these entities are in the very middle of the mix.  Every one of the other factions relies on the payers to keep the balance.  It is an uneasy reliance at that.

End-User
The clinician wants a program that works for them.  This means the program must be developed from the user's point of view not the computer programmer or organizational views.  This means that the needs of the operating room are different than the Emergency Department.  A program with a strong central backbone that integrates with various products designed specifically for that area is desirable.  The user wants walk-up usability (no need for endless training and retraining), easy navigation, crisp interfaces, and easy access to nursing notes, old records, and ancillary service records.  The user wants a cost-benefit analysis of the elimination of the "classic" ward secretary leaving the providers to fend for themselves with minimal support.  The providers should be supported rather than given more "data entry" tasks.  When overall productivity go down and meaningful use money disappears; making the provider more efficient will make the organization more money.  The user wants clinical decision support (Artificial Intelligence), but with a "soft touch" not a hammer.  This will help with malpractice, billing, and ACO support.

Patient
The patient, or should it be said "and then there is the patient..."  Usually the most forgotten in the mix, but also the most important, the bottom line, the raison d'etre for all the others.  Why is the hospital erected, the provider well-studied, the government interested, or the insurance company calculating, if not the this central, key entity...the patient.  More and more, EHRs are actually allowing patients within a system to have certain forms of access to see results, and report status back to the clinicians.  Keep in mind though, if the patient's are not happy...think: long waits, errors, incomprehensible documents...it ain't gonna work.

Bottom-line is the needs of all groups are important, but by enlisting the player who is really the quarterback (the end-user clinician, physician) as a champion, calling the plays calling the shots, one has the best organizational team for success.  By vertically integrating the Electronic Health Record and providing the needs of all five silos, with one quarterback, the EHR will be gladly accepted and not create so much angst.