No waiting! Time to optimize your emergency department’s efficiency.

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As the demand for emergency services grows, resources in emergency medicine are being stretched.  No surprise, but what's being done about longer ER wait times, overcrowding, ambulance diversion, increased patient suffering and poor morale?

One approach that I'm involved with - and is getting real results in hospitals in California, Arizona, Oregon, Washington, Texas, Georgia and Illinois - is our process known as Rapid Medical Evaluation® (RME). First implemented in 2002, RME is considered a best practice at more than 30 facilities.

RME places one or more providers - physician, nurse practitioner or physician assistant - in triage to perform initial medical screening examinations and either order additional testing or treat and release the patient without ever taking up a bed on the unit. The whole focus of RME is how quickly a provider sees a patient and begins a workup. It's also about how you use space and how patients will flow.

The idea is for patients to be seen in an area of the ED appropriate for their condition. Not every patient in the ED needs to lie down, so if they don't, they might not need a bed. With a triage nurse and a provider working together up front, there can be parallel processing. The patient can then be moved to the internal waiting area. Now the waiting time is productive - it's time spent waiting for results instead of waiting for the next thing to happen.

Having the right people up front managing the process and patients is another important part of RME. Just as some nurses are good at triage and others are not, you really need someone who is good at multitasking, anticipating the needs of the providers and keeping things flowing.

Speaking of flowing - our goal for time to provider is less than 30 minutes, turnaround time for discharge patients of no more than 2 hours, lab and imaging to be less than 30 minutes and the left-without-being-seen rate to be less than 2 percent. And you know what, we're doing it.

At Mercy Medical Center Redding (CA), for example, we saw the door to provider time decrease from more than 40 minutes to just nine minutes within the first month of implementation, and ED patients who left without being seen dropped from 3% earlier that month to .2% - a big boon to hospital revenue.

In my experience, RME works. And thanks to everyone including physicians, nurses, lab, imaging, and registration being on the same page, it will continue to work.

I look forward to your comments!

Emergency physicians lost in transition.

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By Prentice Tom, MD

Last year, I experienced two firsts.  I bought a digital single lens reflex (SLR) camera, and I started using my first emergency department electronic medical record (EMR). 

I bought a digital SLR, (Nikon D90) because we were planning a family vacation to Italy, and plain film not only was becoming difficult to find, but I didn't want to lug around a backpack full of film.  Digital SLR cameras have been around since 1991, when Kodak developed the DCS-100, a 1.3 megapixel camera costing approximately $30,000. Over the past 20 years, digital SLR technology has improved and manufacturing costs have dropped, so now digitals offer all of the picture quality of the old school SLRs with much greater functionality and less cost.  Of course, there was about a 10 year transition period, with consumers left in limbo, not wanting to buy a plain film SLR as newer, better and cheaper digital models were on the way. Today, there's no turning back.

The reason I started to use an EMR was simple.  My hospital wanted to switch from dictated records to digitally generated records.  The electronic EMR met my hospital's goal of moving to digital information storage, which will someday improve transportability, access to, and accuracy of medical information.  Unfortunately, we're still in that transition period. Documenting is slower, more tedious, and less accurate with less information recorded.  At a minimum, my efficiency and productivity have suffered.  Other clinicians wanting to understand a patient's ED course have less information as to my diagnostic reasoning, the course of events, and my disposition thought process. 

I have long predicted that technology will result in substantial medical cost savings, increased productivity, decreased errors, and improved information transfer.  Physicians will walk around with wireless headsets, and will simply state:  "I would like my standard chest pain labs ordered on the John Doe in ED room 3," and the orders will be immediately transmitted.  Voice recognition software plus use of macros will speed documentation, and digital records will allow us to instantaneously study any physician or patient parameter with a few well placed keystrokes. 

For example, we could review how many head CTs I ordered on pediatric patients with headache, and compare my ordering patterns with any other physician, as all the information will be digitally archived. 

The ability of regulatory agencies to profile physician practice patterns will be limitless.  Immediate error free order entry, greater uniformity in practice, the ability to educate physicians on practice patterns and to quickly review and improve patient outcomes are all promises of the EMR.  Unfortunately, the transition is not painless, and for now, we're stuck with the 4.0 megapixel version of the EMR - lost in transition limbo.

I look forward to your comments.

Medical emergency in Haiti calls for physicians and nurses.

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By Joel A. Stettner, MD

As an emergency physician, I've seen a lot of things during my career, but perhaps nothing as heart-rending as the widespread suffering in Haiti. The recent earthquake continues to have a devastating effect on that impoverished country. So many photos and videos show areas that have literally been leveled, and people struggling to find adequate food, water, and shelter. Even the most basic services for treating the injured and supporting other survivors remain inadequate in the face of overwhelming demand.

As of this writing, the U.S. Department of Health and Human Services (HHS) has activated the National Disaster Medical System and the U.S. Public Health Service Commissioned Corps. More than 250 personnel are in the process of deploying to Haiti and over 12,000 others could possibly assist in the coming days.

On a positive note, medical personnel from across the country and around the world are traveling to Haiti to provide emergency medical care. These professionals - including emergency physicians and nurses - are treating the injured and will support the public health response on the ground. Additional medical personnel are being deployed to help address the many critical health issues that will be part of the earthquake's aftermath.

As an emergency physician, I'm proud of the efforts that our physician and nursing colleagues across the country are making in response to this disaster. Monetary donations have helped obtain and ship needed supplies; personal commitment has provided staffing for medical teams who are on the ground in field hospitals and mobile clinics. Partners from our group are active participants in this work.

The Haitian tragedy is a reminder of the unpredictable aspect of natural disasters. The immediate and powerful response of so many people from so many countries is testimony supporting the human bonds we all share. Perhaps we can build on these bonds, knowing that another cataclysmic event could strike elsewhere at any time.

I welcome your comments.

Are emergency physicians missing opportunities to listen?

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By John Ruffner

"If you listen, the patient will tell you what's wrong" is a great quote from a conversation I had with the chief of staff at a large teaching hospital.  As an emergency physician, listening turns out to be pretty important not only for clinical decision making but for establishing a positive patient/ physician relationship.

But for many in the emergency department, truly listening is perceived as giving up some control - which can be difficult for some emergency physicians to do. After all, the doc is the expert, right? But in my opinion, not listening is a missed opportunity to provide the patient with the most accurate and compassionate treatment possible.

Think about the times in your life when you've felt you weren't being heard - and the sense of frustration that goes along with it. How did you react?  Here are a couple of recent examples from my own experiences:

• I was at a restaurant ordering dinner when a member of our party commented that they had been there last night and their dish was not prepared properly. The waitress responded in a dismissive tone that she wasn't working the night before and left our table---- a missed opportunity to hear our concerns and address them. How would you have handled this situation differently if you were the waitress?

• I recently needed to change flights at LAX. The Customer Service Desk was closed so I approached an airline staffer and indicated I needed some help. I then got a long explanation about how they didn't have staff anymore for Customer Service and he never got to my question. A missed opportunity to listen and help. Have you ever heard the "don't have staff" explanation in the hospital? How would you have handled this situation differently if you were the airline employee?

My point is that listening is a positive.  For clinical purposes, this means physicians get important information from the patient and the patient feels we're hearing and understanding their problem. Listening means that instead of clinicians making diagnostic decisions based upon a few familiar solutions, treatments are carried out based on what the patient is actually saying is wrong.  You'll also be amazed at how your patient satisfaction scores will trend upward.

Thank you for taking the time to listen - I look forward to your comments.

An emergency physician’s wish for tort reform.

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By Marty Ogle MD

As an emergency physician and part of a national emergency physician partnership - I keep hoping for the best in regards to tort reform. If only pigs could fly.

As you likely know, Tort reform refers to proposed changes in the system that would reduce tort litigation or damages. "Tort" is a system for compensating wrongs and harm done by one party to another's person, property or other protected interests. Sounds pretty logical, but of course, as in many things in the U.S., tort reform is a contentious political issue.

Nowhere is this more apparent than with healthcare tort reform as it relates to eliminating the "friction" in the system that wastes dollars. These wasted dollars are most often diverted to lawyers, malpractice insurance companies, etc.

Aside from billing costs - which could ultimately be reduced by requiring one standard billing form/procedure for ALL payors- medical malpractice coverage is the single largest expense in an emergency medicine practice. And yet, tort reform appears to be off the table - hmmm, I wonder if it's because most members of the U.S Congress and Senate are lawyers...nah!!!

So what to do? You can certainly let your representatives know that tort reform needs to be back on the table; that true, cost-effective healthcare reform can't happen without it. It may seem like our government isn't listening. Or they're listening to the wrong people. But if enough of us raise our voices, funny things can happen.  Like real, honest tort reform?

Here are two excellent links: 

http://www.calacep.org/advocacy/  (Advocacy Section)

http://www.acep.org/   (Advocacy Section)

I look forward to your comments.  

Do Emergency Physicians qualify for the $44,000 Medicare EHR?

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By Ellis Weeker MD

For emergency physicians and emergency departments, last week's announcement by the Centers for Medicare & Medicaid Services (CMS) should prove useful.

The CMS has defined the requirements eligible professionals must meet to be considered "meaningful users" of an electronic health record (EHR) system. "Meaningful users" of an EHR can be reimbursed for up to $44,000 for adopting a "certified" system under the Medicare incentive program and up to $63,750 under the Medicaid program.

Medicare penalties begin in 2015 for those who have not complied. Since the first incentive payments will be available in 2011, a large number of medical groups are expected to begin the transition to EHRs in 2010.

The CMS proposed rule outlines 25 objectives and corresponding measures that practices would be required to meet to qualify for the incentives.  These include:

• Use of computerized provider order entry (CPOE) for at least 80 percent of all orders
• Provide patients with an electronic copy of their medical record within 48 hours of a request
• Incorporate at least 50 percent of all clinical lab tests in a structured (electronic) format
• Implement five clinical decision support rules relevant to the provider's medical specialty
• Provide clinical summaries to patients for at least 80 percent of all office visits
• Provide timely access to health information through a Web-based patient portal for at least 10 percent of all unique patients

The requirements outlined in the document provided by the CMS are a long way from becoming law and comments are being taken for the next 60 days. I suggest you read through it as best you can and comment as you see fit. The easiest way to comment is electronically at http://www.regulations.gov/. They ask that you refer to file code CMS-0033-P.

In addition, MGMA has developed a comprehensive three-part Webinar series to help understand the specifics of the incentive program.

I look forward to your comments.

Here's to a positive year for emergency medicine.

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This first blog of the New Year focuses on some of the interesting stories you may have missed over the past few days. In the coming weeks, we'll be touching on the relevant and timely issues that affect emergency medicine and the emergency physicians and PAs who work so diligently to make a difference. So visit often.

We begin where we left off - with Healthcare Reform. Right before Christmas the Senate approved its healthcare reform bill. And now the complicated process lies ahead to reconcile this bill with the House bill, which was approved last month. An article 10 issues that Congress will need to resolve in final reform bill, published in HealthLeaders Media, outlines the work still needed to be done.

An interesting story from the Daily Mail in Great Britain on the National Health Service's dictum of a maximum four hour wait time for patients needing emergency treatment. According to their records, a "vast majority" of patients are seen within 3 hours. However it was revealed that hospitals have been fudging the figures. Truth or politics? It's causing quite a heated debate. 

Just this past week, a list of the top ten "overblown healthcare stories" of the past decade was posted in the Healthcare Economist. Not surprisingly the H1N1 pandemic was number one. Coming in at number four is the notion that uninsured patients cause ED overcrowding. An interesting read to be sure.

This story from the Los Angeles Times highlights a unique Chicago-area doc who is both trauma surgeon and SWAT team member. If you think your day is stressful -- read this!

And finally, an article posted on the Wall Street Journal reminds us that the Congressional stimulus bill passed back in February allows for docs and hospitals that make "meaningful use" of electronic medical records to receive big bonus payments from Medicare and Medicaid. The government released details last week on how to qualify for the money. Read the facts in How to Get $20 Billion for Using Electronic Medical Records.

As always, this page welcomes your comments and observations.