Why the Consumer “Loves” the Emergency Department

The article US Emergency-room Visits Keep Climbing posted in the Wall Street Journal reports the not unexpected rise in Emergency department visits.  This was an easily predictable event.  Despite the official pronouncements that the Affordable Care Act would limit such events, there are multiple reasons for the rise:

1. Lack of access.  With the addition of multiple new Medicaid patients, without the adequate primary care infrastructure, these patients are voting with their feet.
2. High deductible health insurance plans that are de facto catastrophic self-pay policies.  The consumer cannot afford both the premiums and the deductible on their salaries.  They make the choice of care, which the Emergency department provides without mandatory upfront payments.
3. The Emergency departments, in general with all their technology, access to specialists, convenience, and board certified/experienced physicians, make an attractive package.
4. Private practice phone trees start out with call 911 and then, go to the Emergency department.
5. The Emergency department has the capacity to do an extensive medical evaluation that might take 4-6 weeks with multiple appointments in under 4-6 hours.
6. Immediate gratification of the consumer.
7. Emergency departments advertise wait times- patients will be seen in under 30 minutes and special Fast-track aka Urgent care areas for low acuity patients.
8. Call ahead or online appointments in the Emergency department.
9. Primary physicians' use of the expertise and technology of the Emergency department as an extension of their practices.
10. Emergency department 24/7 hours of operation.

 

The problem is the cost associated with the ED visit.  The consumer is paying for the 24/7 infrastructure, which is massive.  These include the staff, physicians, Nurse practitioners, Physician assistants, techs of various types, on-call consultants, etc.  The prices are a reflection of the disconnect between charges and costs that are rampant in hospitals and insurance company contracts.  With an appropriate cost and charging scheme, the Emergency department could be quite cost-effective because everything and everybody is already there.

Hospitals and EDs compete for business because they are the main driver of hospital admissions where the money is.  The Fast-Track low acuity patients help pay the freight to generate more admissions. 

One of my prior blogs offers the suggestion that the Emergency department become the center of health care with primary care, specialists and urgent care as the spokes of a wheel.  This would provide constant direct interaction directing the consumer to the best logical point of care.  This is controversial, but reality is when the family member is ill, the first impulse is to go to the Emergency department.

Is Lack of Interoperability a Factor in Emergency Department Revisits and Readmissions?

In the revisit rates and associated costs after an emergency department encounter article, discusses the results and they are complex.  One interesting fact stand out.  The number of patients who seek further health-care from another ED is extremely high.  It is worth reading, but it is difficult to make sweeping judgments or generalizations.

People who return to the ED have multiple forces and motivations in play, including but not limited to:

1.      Convenience

2.      Impaired follow-up access.  For example, even though a patient may be instructed to recheck or follow-up with a primary care physician within a certain time frame, many cannot get a timely appointment without an established primary care network.  Many specialists will not see them without cash or health insurance, and those with coverage may have their access limited by policy requirements and unaffordable co-pays.

3.      Treatment failure.  Some patients do not get better.

4.      Dissatisfaction. Patients may feel their care was inadequate: questions were not addressed, testing was insufficient, or prescriptions given were inadequate or unaffordable.

5.      Narcotic Overlay.  If the patient was previously prescribe a narcotic(s) and/or wanted to receive a narcotic prescription that was not given, an added dimension for returning to (some) ED, is present.

6.      Mental Disturbance.  Many individuals have underlying psychological problems along with inadequate local community psychiatric/social support.  When a social worker is not available, some patients seek this kind of support from the ED, despite an actual need for individualized social services.

7.      The patient likes the ED or a particular ED doctor. 

These are extremely complex system level problems.  A potential solution may be to provide a social worker to help sort out the medical system, in addition to simply handing the patient discharge instructions.  Some institutions have established a system along these lines, called a medical advocate system.

Going to a different Emergency Department for a second or third visit seems to be a part of this phenomenon.  And there, in particular, is where the issue of interoperability arises.  Let’s assume that your EHR system is inherently good enough for internal interoperability, and that you have access to all the prior records- Right??  Now what about when the patient shows up across the river?  Would life not be simpler if each emergency department’s electronic health record had the interoperability capacity to talk to each other, to share data, and relate to the second ED what the first encountered and found?  This might lessen the need for repeating the entire work-up and admitting the patient.

Of course, from a practical standpoint, patients who are evidently sicker and return to the same or different emergency department usually get admitted to the hospital.  Repeat discharge happens, ut it does so with peril, as there are frequently solid medical, medical-legal, and logistic reasons, to keep the patient the second time.  Because beware willing to send home potential high risk bounce-back patients overall costs are inevitably driven up.
True interoperability, particularly by the establishment of industry-standard and required electronic documents, would greatly enhance patient safety by giving the next provider a better feel for what might have occurred at prior visits.

We're on the "Eve of Destruction"

In the song We're on the Eve of Destruction, singer Barry McGuire laments the end of western civilization due to endless worldwide strife in the 1960-1970's.  In the article The Awful (and not so creative) Destruction of Medicine, a similar argument is made for the end of private practice medicine in the United States.

The author of the article states that only 30% of physicians remain in private practice and that the "Marcus Welby Era" is long deceased.  The endless new government mandates are eliminating the private practitioner.

The physician is now part of interchangeable puzzle where everyone especially the payers have a say in the patient care and reimbursement.  The physician is no longer the centerpiece of healthcare.  The article makes a strong case that the modern day era of medicine from 1960-present is essentially over and rapidly changing.

What's a classically trained physician to do???

The best solution is to view the rapid change and chaos as an opportunity rather than a huge negative.  Realize that before Medicare started paying physicians in the 1960s that medical care was totally different.  Periods end and new approaches need to be analyzed and taken advantage of.

Potential Solutions:

1. Take some business classes or get an MBA
2. Attend some coding and reimbursement classes
3. Analyze and embrace your technology
4. The age of automatic physician entitlement is over.  This doesn't mean it still cannot be fulfilling and financially sustainable.
5. Your Medical degree is a ticket to multiple opportunities
6. Attend a meaningful use lecture or two
7. Understand that the accountable care organization (ACO) is code for 21- 1st century HMO.
8. Rethink your hiring practices.  Get professional consultations to get improved financial situations.  Hire consultants not employees.
9. Pick software that pays for itself downstream.
10. Learn the new rules and adapt
11. Realize to succeed you will need the proper software, highly trained medical assistants, and possibly voice activated technology such as Dragon to make one complete medical technology unit.

The future is still bright for the agile and well informed.  Make your theme song, The Future's so Bright, I Gotta Wear Shades.

Avoiding the Potential Legal Quicksand of Opening ann Urgent Care

Opening an urgent care can be a fulfilling experience but to be successful takes more than good medical care.

The Top Four Legal Issues to Consider When Opening an Urgent Care Center article describes significant legal issues that need to be considered during the planning stages. In addition to the usual components of a business such as location, leadership, work-flow processes, and timing; the medical business has certain legal concerns.

1.       Corporate practice of medicine is outlawed in some states and mechanisms including a “friendly PC” model can be used.

2.       State licensure requirements including a CLIA certificate of waiver for laboratory testing, x-ray permits, and any other licenses needed in that state.

3.       Understanding any EMTALA requirements is key to the viability of the center. Particular attention needs to be paid to the “naming of the center”.  Adding the word Emergency will imply, the center is a 24 hour practice that is specifically under the EMTALA laws. Hospital owned urgent cares must have their legal team evaluate any responsibility to the law.

4.       Have your insurance contracts in order prior to opening or face a potential cash flow issue. These negotiations take time.

Some other issues of particular significance are:

1.       Location, Location, Location

2.       Times of service

3.       Types of providers

4.       Credentialing those providers. This is a cumbersome time consuming task which may need to be outsourced.

5.       Marketing-Establishing contact with the local community by providing school physicals, blood pressure checks, flu shots, etc.

6.       Being undercapitalized and suffering cash flow issues

7.       Picking an Electronic Health Record and Practice Management system that is efficient and pays for itself.

8.       Understanding the difference between using a billing company and doing self-billing.

9.       Hiring the right practice manager.

10.     Not expecting a “paycheck” right away.

11.     Fill in the blanks

12.     Hiring a consultant to help with the start-up, if these steps are too daunting or too much aggravation.

With a proper vision, an urgent care can be an enjoyable way to provide quality medical care. This can lead to career longevity and adequate reimbursement.

Single Payer System vs. the Present American Health-care System: A Personal Experience

The following medical experiences happened to my extended family.  They show the multiple complex problems in providing medical care at an affordable price.  The people involved have given me permission to give brief details of their journey through the medical world.

The first patient is a young male who experienced multiple episodes of tachycardia (fast heartbeat), sweating, anxiety, stress, headache, and weakness for greater than 3 years.  He had high blood pressure while on multiple medications with minimal control.  His friend consulted me about what could be wrong as she had witnessed several events herself, and decided he wasn't exaggerating or having a panic attack.

We looked up pheochromocytoma also known as PCC is a neuroendocrine tumor of the adrenal glands that secretes high amounts of catecholamines, mostly norepinephrine, plus epinephrine to a lesser extent.  His symptom complex matched 9 out of 10 on Google.  She wrote down the potential diagnosis and suggested work-up.  She presented what she had found to his doctor.

The patient is a Spanish citizen on a national health insurance.  The doctor had never heard of this illness, but referred him for testing.  It took approximately 60 days to get a specific urine test, which tested positive.  He was then referred to the specialists where he was admitted and waited 5 days for a cat scan to confirm and locate the tumor.  He was operated on 2 months later and is doing well.

Pheochromocytomas are a potentially high risk problem leading to stroke and other cardiovascular events.  He received multiple medications to control his blood pressure with multiple negative side effects.  He is off most of his medications now.

The problem was taken care of, but took 6  months.  His personal direct cost was negligible, but indirect costs including problems at work, anxiety, and stress were very high.

Our second patient is a young female with non-ruptured appendicitis who went to the emergency room in the US.  She was diagnosed and sent to the hospital for outpatient surgery.  She was discharged from the surgical area 6 hours post-operatively.  She made an uneventful recovery.

Her care was excellent, but the downside is she has a $10,000 deductible health insurance plan.  She is basically a de-facto high deductible insurance self-pay patient.  Her bill including emergency department, diagnostic tests, ER physician, radiologist, anesthesiologist, operating room and surgeon was approximately $47,000.  The event lasted less than 24 hours and shows the major disconnect between actual costs, charges, write-offs, and negotiated prices per insurance plan.

As health care costs spiral out of control, these two examples at different ends of the spectrum show the fundamental flaws in both systems.  The present system does not work for the low-income high-deductible patient (majority of people).  The single payer system probably does not cost less, but spread the costs over the entire population.  The price is lack of efficiency and time wasted.

These real-life examples create an interesting dichotomy.

Cost of a Click

In the article The Hidden Cost of a Click, the author states, “A bad user interface can turn an EMR/HER into a minefield of medical errors and inefficiency.”

 

At the present time, the number of clicks necessary to fill out a chart is endlessly time consuming and non-productive.  The cost per click is now being calculated and quantified.  The work flow is slowed down and there is a real-not imagined- price to pay.

One solution is to create an auto-flow sequence that is tunable by site or provider and that comfortably guides the clinician from one area of the chart to another in a logical-customary- sequence.  If an out of sequence entry is desired, this should be easily accomplished.  A system with automatic guidance will eliminate the need to figure out where one should go next, especially if one is interrupted.  When it is acknowledged that one area is complete, it then moves to the next area when documentation is continued or resumed.  Once the area is completed, the list shrinks.  Your favorite click might be auto-sequenced.

An example sequence could be...

• Vital signs
• Triage sheet
•  Past medical history
•  Nursing notes
• History and PE in logical order
• Medical decision making
• CPOE
• Lab and x-ray results
• Clinical course
• Final diagnosis
• Disposition
• e-Prescribing
• Patient education
• Follow-up
• Review nursing notes
• Sign the chart

Navigation would be significantly simplified.  The provider can always go to any area directly and in any order.  Nursing notes might be reviewed, if easily accessible.  Training would be simplified and hopefully stress-reduced.

Danger, Danger Will Robinson

As Electronic Medical Records mature, the legal community is getting the handle on how to use the volumes of data, timelines, and computer speak to win more cases.  Vulnerability is greater and more complex than in the paper world, as some unintended misrepresentation of the care given may be more hidden, and therefore not as evident to you, and therefore not as evident and open to inspection and correction.  The article EMRs can be costly in malpractice suits have the basic message in the title.

Some prominent points:

1. Lawyers are attending conferences on how to attack the electronic medical record
2. Losing lab and x-ray data through failures in tracking
3. Cut and paste was called "plagiarism" by the judge
4. Using auto-complete without confirming the information
5. Avoiding complex notes that are incoherent
6. Understanding the limitations of electronic signatures
7. Being careful with templates
8. Lack of individualized information about the particular patient
9. Gender confusion
10. Positive findings in 1 section noted negative in another section
11. Alert fatigue mistakes
12. Typos and large number of empty spaces

Clearly, the electronic health record is both a theoretically great solution and a minefield of potential legal issues.  It is important to keep this in mind when signing off on the EHR record of any patient, and to choose an EHR which helps you verify the correctness of the final data recorded.

The provider must never forget that the computer automatically captures the timeline of documentation in the document.  However, that recorded timeline may not accurately represent the sequence of care.  It is thus important to state the actual timeline (sequence, preferably with times) of clinical events in the clinical course of the medical decision making.  Many cases that go to trial hinge on a comparison of times between the records made by the physician, the nurses, the other staff, and yes, now, the computer.

Read the final output before signing.  A few words or sentences typed or dictated through voice-activated technology (e.g. Dragon) can insert meaning and coherence into an automatically synthesized notation that otherwise would read like "electric babble".  Read the nursing notes.  Explain any discrepancies.  Read that last sentence again. 
Acknowledge warning alerts and state in the record your medically appropriate decision, along with a brief summary of the basis for that decision. 

The cost and complications of the electronic health record will continue to rise until the process is simplified and designed for end-users.  It is going to get worse, before it gets better.