Healthcare reform bill by Christmas?

Unlike emergency departments and many emergency physicians, this blog will be taking the next several days off, returning the week of January 4th, 2010. In the meantime, we hope you enjoy a happy and safe Holiday season.

But before we sign off, this space would be remiss to not mention today's news that the AMA has officially thrown its support for the Senate's health reform package after it won assurances from lawmakers that they would work to craft a long-term solution for Medicare payment come January 2010.

Appearing with Senate leaders, Cecil Wilson, president-elect of the American Medical Association, cited a number of health insurance and other provisions that stress wellness and prevention as some of the reasons it would back the bill. President Obama is optimistic that a bill can be passed by Christmas.

Part of the association's support is based on lawmakers shaping a long-term fix to the Medicare payment formula.

The original Senate bill included a measure that would permanently erase a 21% pay cut in 2010 with a 0.5% increase, but an amendment, filed on Saturday, squashed the provision.

Additionally, the AMA also fought against a measure that would have required physicians to pay a $200 fee each year for treating Medicare and Medicaid patients.

So who knows?  By January we may be talking about the passage of heathcare reform legislation. After all, this IS the season for dreams.

Happy Holidays!

Health Information Exchanges: the "next great leap" in emergency medicine.

 By Ellis Weeker, M.D.

As we look ahead to a new year, it's clear to me that one of the hot topics for emergency physicians - and emergency medicine -in 2010 will be the concept of Health Information Exchanges (HIEs). For those who don't know, a HIE is defined as the mobilization of healthcare information electronically across organizations within a region, community or hospital system. 

The goal of Health Information Exchange is to facilitate access to and retrieval of clinical data to provide safer, more timely, efficient, and equitable patient-centered care. A HIE is especially important for emergency physicians and practioners who most likely know very little about the patients they treat -- especially in situations where an ambulance is dispatched for rapid response.

There are many times that patients and their families cannot give an adequate history with essential information relating to history, diagnosis, laboratory/diagnostic imaging and medication. HIEs in current use in Great Britain provide a sophisticated summary of all of this information plus the latest visits to the patient's physicians. All of this is accessible via the Internet and is encrypted to protect the patient's privacy. These systems will be coming to the U.S. in the next year or so and will become available to emergency physicians.

By placing the cursor on the items on the screens, more information and/or images are brought up for review. This should eliminate much of the guess work and duplicative ordering of tests that now occurs in EDs. In addition, the most sophisticated HIEs place all of the patient's medical information in a relational data base that allows real time access to the care of all patients in the system provided for instant epidemiological studies without any special programming. This means there improved clinical administration of patient care on a large scale as well as for scientific outcomes studies.

I look forward to your comments.

Texas proposal could leave emergency patients on the outside looking in.

By Dan Culhane, M.D.

As published in a recently published story, Texas state health officials are discussing the merits of changing a requirement that Texas emergency rooms have a physician on-site at all times, as long as a physician can get to the hospital within 30 minutes.

According to the story, the proposed change would ease financial strain on small specialty hospitals. These facilities are required to have emergency rooms, yet they have very low emergency room traffic.

On the face of it, the proposed change makes financial sense. Why should a hospital with very few ER patients have to pay for on site ER physicians 24/7?

But opponents say the proposal would create risks for patients coming to emergency rooms with the need to see a doctor immediately. What's more, there's the fear that hospitals trying to avoid costs would eliminate on-site ER docs to avoid uninsured patients - and instead specialize in high-dollar/high-profit surgical procedures.

My view on the proposal is that the status quo requires all hospitals to provide emergency services, and thus spreads out uninsured and underinsured patients. In the absence of a system that provides health care for a higher percentage of Americans, I'm in favor of spreading the care for the uninsured around.

This issue might be less contentious if we provided adequate coverage for more of our citizens. If everyone had quality coverage that provided for emergency care I suspect this would be much less of an issue.

I look forward to your comments.

Healthcare reform: can we all just pass something already?

By Joel A. Stettner, M.D.

Enacting a healthcare reform bill is obviously a very complicated, methodical and political process. Personally, I don't mind vigorous and open debate on legislation that has the potential to dramatically affect physicians, hospitals, insurers, and patients.

What I do mind is the inability of the House and Senate to find some middle ground and hammer out a bill. You know the drill: the Democrats, barely in charge based on votes, propose legislation - but not until many of the true reforms are removed to please the "Blue Dogs".  However, that doesn't sit well with the liberals in the party, who balk at attempts to "gut" alternatives, such as a public option, out of the bill.  

And then there are the Republicans - who give new meaning to the word "no". They're not budging - and they're not helping to reach the afore-mentioned middle ground.  After all, the "base," or what's left of it, must be satisfied.

What's more, both parties are obligated to those many special interests that are able to buy access and peddle influence.

But now, AARP has re-entered the fray. Could this be the needed impetus to help the Democrats take advantage of their 60 seat majority in the Senate - and actually pass a bill?  

According to this Associated Press article, last week the AARP "rode to the rescue" of Democrats, supporting $460 billion in Medicare cuts to help pay for health insurance legislation. AARP has played an influential role all year on health care, working with the Obama administration and Democratic congressional leaders to help pass legislation. Polls show them enjoying a large amount of trust among seniors - who tend to vote - which means their endorsement is highly regarded.

And so we wait - stuck in a political process that does not seem to change, with the concept of "bipartisanship" as elusive as ever. Lobbying reform apparently has had no real impact, and special interests, including AARP, continue to hinder meaningful reform while the number of uninsured Americans continues to climb.

Well, sooner or later something will happen. In the meantime, you might take a look at this article, which appears in HealthLeaders Media, which explains how we're going to pay for whatever is in the final bill.

I look forward to hearing your thoughts.

Many American surgeons are suffering from burnout. But what about emergency physicians?

By Ellis Weeker, M.D.

As an emergency physician who's no stranger to working long shifts, a recent study in the online version of the Annals of Surgery caught my eye.  In it, nearly 9% of the 8,000 members surveyed from the American College of Surgeons said they'd made a major medical error or lapse in judgment within the last three months. The reason?  The study found that 40% of the surgeons who responded said they were burned out and/or depressed.  

The authors stated that in August, the same group of researchers reported in the Annals of Surgery that burnout is common among American surgeons and is the single greatest predictor of surgeons' satisfaction with career.

So what about emergency medicine - and the physicians who diligently work long, often stressful shifts? It's true that we talk about fatigue and long working hours. But as emergency physicians, what are we doing to ensure we're not becoming burnout cases or suffering from depression as the study suggests with surgeons?

Working in an emergency department is a mixture of exhilaration and challenge, which creates both physical and mental stress. Yet we know that patients in the emergency room need their treating physicians to be attentive, alert and at the top of their game.  This means being fresh and not over-working ourselves - an ideal we don't always achieve.

Often emergency physicians try to squeeze as many shifts as possible into the beginning or end of a month to take a long stretch of time off in between. PAs and NPs also succumb to the siren sound of far away adventures, only achievable by taking long stretches of time off and then trying to cram as many shifts as possible into the remaining time frame to pay for it.

The other trap is to live beyond our means, causing us to work more shifts than we can tolerate, and reducing our effectiveness as physicians.

The antidote is to pace yourself. Remember, emergency medicine can be a long and satisfying career if you don't burn out. And you will provide better care to your patients.

Only work the number of shifts you can handle and don't try to compress them into short time frames. If you want to take a long vacation, place the extra shifts into other months of the year to compensate. And lastly, live within your means.

I look forward to your comments.

The importance of including IT in hospital disaster planning

By Nancy Burghart-Hall

As we move closer to winter, weather-related disasters can often become a concern for hospitals. With more facilities increasing their reliance on IT, systems going down as part of a disaster will have widespread negative effects on the clinical front line, the emergency room - and on how information is communicated.

A recent article published in HealthLeaders Media discusses the importance of including IT in a hospital's staged disaster drills. The reasons seem obvious, but the fact is, IT recovery is often not factored into a hospital's disaster plan.

According to the article, conducting risk assessments is a good start to uncovering IT-related and other vulnerabilities in advance of a real disaster:

Identify threats Consider the risks to your organization using the categories of natural threats (e.g., tornadoes, hurricanes, snow storms, and floods), human threats (e.g., staff shortages), and environmental threats (e.g., power failures)

Recognize vulnerabilities What if your emergency generator is in the basement and you're in a flood prone or hurricane area? The likelihood that you will lose electric power-and potentially IT systems-because of flooding is a vulnerability. What if your datacenter is in the basement - is the floor raised to protect the equipment from water? And what about the power lines - are they overhead or under the floor?

Determine the effect If a flood causes you to lose power, what other problems will it lead to? How will this affect your hospital?

Develop a list of remediation activities Figure out possible steps to offset the various threats and vulnerabilities you've identified

A logical approach to hospital disaster planning is vital.  And so is including IT in the equation. Is your hospital prepared?  How has IT been brought into the loop? I look forward to your comments.

 

Troubling study shows uninsured ER patients are twice as likely to die.

By Barbara Victor, M.D.

How are the uninsured faring under our present healthcare system? A recent study by Harvard University researchers, and published in the November issue of Archives of Surgery, paints a grim picture.

According to the study, uninsured patients suffering from traumatic injuries caused by car crashes, falls and gunshot wounds, are almost twice as likely to die in the hospital as similarly injured patients with health insurance.  This flies in the face of what many physicians and health experts had previously believed.

Though researchers couldn't pinpoint the exact reasons behind their findings, the takeaway is that the majority of uninsured patients are treated differently  than insured patients.  For example, the uninsured might experience delays being transferred from hospital to hospital - with some private hospitals more likely to transfer an uninsured patient than an insured patient. The uninsured might receive different care. Or the hospitals that treat them may have fewer resources and lower levels of staffing.

From my perspective, it's hard to believe the results. I feel like there needs to be further studies in the area of trauma care. I've worked in three large Los Angeles County Trauma Centers and observed the highest quality trauma care that the United States can provide. In my experience, the care was always given without any consideration of medical insurance coverage. The Trauma Center hospitals readily accept anyone from outside hospitals without reservation. But my experience is in California only.  If the results are true cross the country, then we as doctors and care givers are not doing our job. 

In the study, the overall death rate was 4.7%. The commercially insured patients had a death rate of 3.3%. The uninsured patients' death rate was 5.7%. Those rates were before adjustments for other risk factors and are based on data analysis from the National Trauma Data Bank, which includes more than 900 U.S. hospitals.

How is your emergency department coping with uninsured patients? And what are your thoughts on the study's findings?

Congress approved a Medicare/physician payment revamp. But don’t rejoice just yet.

By Marty Ogle, M.D.

As hoped for, the House of Representatives voted late last week to approve legislation that seeks to reform the way Medicare pays physicians, aiming to prevent a scheduled 21.2% rate decrease set to take effect next year.  Next up is the Senate. But as this weekend proved with the healthcare debate, getting a bill passed in that hallowed body can often be a real challenge.

The House legislation would specifically revamp Medicare's sustainable growth-rate, or SGR, formula, which is based on the economy's health, and has produced results that would have resulted in payment cuts to physicians every year since 2003. Congress has stepped in each time to enact a temporary fix so that doctors won't experience additional reductions to their Medicare payments. However, a few years ago, Congress waited to rescind the SGR cut after it had already taken effect - causing a variety of administrative problems. 

In return for the bill - called the Medicare Physician Payment Reform Act of 2009 - Rep. Henry Waxman (D-Calif.), chairman of House Energy and Commerce Committee, has made it clear that he expects physicians to provide care more efficiently. "In return we need to pay them fairly for their efforts."

As with all legislative efforts these days, the bill has it supporters - and its skeptics. Republicans called the measure a political payoff to the physician lobby. GOP members argued the bill would increase Medicare premiums and would add to the federal deficit. The SGR fix under a budget agreement reached earlier this year is exempt from so-called "paygo" rules, meaning it's not offset by cuts elsewhere.

Now that the House has passed its legislation, the Senate has several options on how it may proceed on the SGR fix. There is still work to be done and the heat needs to be kept on. So I ask my fellow physicians to continue to speak up as an advocate for this very important legislation!

Emergency Department wait times are increasing according to Yale University study.

By Prentice Tom, M.D.

On Tuesday, November 10, NPR discussed how emergency department waiting time has been increasing and referred to an article published in the latest issue of Archives of Internal Medicine that detailed how the percentage of emergency patients seen by a physician within the recommended timeframe has steadily declined since 1997. 

The study goes on to say that prolonged emergency department wait times decrease patient satisfaction, limit access, increase patients who leave without being seen, and can be dangerous for patients coming to the ER with significant disease or trauma.  The study's authors discussed a number of possible causes for increased wait times including increased per capita ED use, high hospital occupancy rates resulting in inability to move patients from the ED to inpatient beds, ED inefficiencies and even physician preference for patients with certain chief complaints.

Increased emergency patient wait time is no doubt complex and multifactorial.  However, there are a number of simple steps that emergency departments can take to dramatically decrease wait time, so that the large majority of patients can be seen within the recommended time frame.  As Chief Medical Officer for a nationwide group of almost one thousand emergency physician specialists that treat over 3,000,000 emergency patients per year, I have seen first hand how improving emergency department efficiency by re-engineering front-end flow can overcome the many barriers to providing safe and rapid emergency care.

I have co-authored a white paper on this reproducible methodology that illustrates how we can redesign ED patient flow to improve the delivery of health care in the United States.  This white paper - entitled the CEP America Rapid Medical Evaluation (RME^®) Program is available to any public health care institution by sending an email request to: hannanc@medamerica.com.   I look forward to your thoughts and comments about this blog.

So far, vaccine allocations not keeping up with H1N1 cases.

By Marty Ogle, M.D.

Here's some encouraging news for my emergency physician colleagues.  According to a story in the LA Times, more than 38 million doses of vaccine for the H1N1 influenza are now available for ordering - 11 million more than last week and double the number available two weeks ago. These figures come from the Centers for Disease Control and Prevention. Another 8 million doses are expected to arrive this week, says Dr. Anne Schuchat, director of the CDC's National Center for Immunization and Respiratory Diseases. 

About 91 million doses of seasonal flu vaccine have also been shipped, and manufacturers expect to ship a record 114 million doses before the season is over, she said.

The not so good news is that widespread influenza activity is being seen in 48 states and, according to Dr. Schuchat, virtually all of those cases are H1N1. Influenza-like illnesses during the first week of November accounted for 7.7% of visits to doctors' offices, down slightly from 8% the week before, but still much higher than in a "normal" flu season.

Other interesting stats:

• More than half of the hospitalizations continue to be in people under are 25.
• 90% of the deaths are in people under 65. In a typical flu season, the majority of deaths are in those over 65.
• There have now been 129 pediatric deaths from laboratory-confirmed swine flu, and the number is increasing.

The CDC has ordered 10,000 treatment courses of the intravenous antiviral drug peramivir for its national stockpile. Meanwhile, the Food and Drug Administration approved emergency use of the experimental drug for severely ill patients who for one reason or another cannot use the oral or intranasal antivirals.  

All of which means, the H1N1 pandemic is definitely here. Even cats are getting it. Emergency rooms need to be ready - not just for H1N1 cases, but for seasonal flu cases. While the best way to combat the flu is to stay home until symptoms are gone, it's unlikely most people will do this (especially in this economy where many folks are afraid to miss work). The bottom line is we need to be on our toes for a long winter. 

How is your emergency department coping with H1N1? Is your vaccine allocation keeping pace with need?  Please forward your comments.

Reduction in Medicare Physician Fee Schedule still moving forward

By Ellis Weeker, M.D.

Last Friday,  the Centers for Medicare and Medicaid Services (CMS) released the 2010 Physician Fee Schedule Final Rule.  The agency is announcing that unless Congress intervenes to prevent the cut from occurring, there will be a 21.2% reduction in the Medicare physician fee schedule conversion factor, effective January 1, 2010. 

This proposed reduction is due to Congress failing to permanently address the Sustainable Growth Rate (SGR)  formula used to calculate annual updates in physician payments under Medicare.   

At present, Congress is debating various ways to address the SGR problem but as of this writing, they have been unable to pass legislation.  It's possible that Congress could include a temporary fix in the healthcare reform legislation, but nothing is set in stone at this point. If Congress fails to rescind the SGR cut before early December, it's possible the cut could take place only to be rescinded later as has happened in the past.

The challenge is not coming up with an alternative to the SGR formula, but figuring out how to pay for the fix.  According to the Congressional Budget Office, simply freezing physician payments for the next 10 years, in lieu of the scheduled cuts, would increase the deficit in the Medicare Trust Fund by more than $240 Billion over the next 10 years. 

While it's likely that Congress will take action to prevent the 21.2% cut from taking place, it's still not certain.  Click on this link to voice your concern to  strongly encourage Congress to fix this situation soon enough to prevent the types of administrative problems that occurred a few years ago - when Congress rescinded the SGR cut after it had already taken effect. 

This is an important time to let your voice be heard, so please take a moment to contact your Senator and Representative today.

Healthcare reform: can Emergency Medicine survive a fifth public option?

By Wesley A. Curry, M.D.

I'm not the first healthcare professional to point out that this country already has variants of a "public option" in health care. The Senate's latest rendition will hopefully reverse a trend and not further burden hospitals and ER physicians with more uncompensated care. But the fact is any new program will be the "fifth" public option since 1965. And each one has ultimately increased the economic challenges on the emergency care system.

The existing public option variants are Medicare and Medicaid, both established in 1965 and both obviously financed by tax payer revenue. Another is the Health Maintenance Organization Act of 1973, which gives HMOs certain economic advantages including the ability to force non participating physicians and hospitals to accept lower reimbursement for treatment of HMO patients. Lastly there's the Emergency Medical Treatment and Active Labor Act (EMTALA) of 1986, an unfunded mandate that ensures public access to emergency services regardless of the individual's ability to pay.

Medicare and Medicaid patients are becoming less desirable to healthcare providers because of decreasing reimbursement rates (legislated decreases or because rates have failed to keep up with inflation). That means more people are coming to hospitals under the mandates of EMTALA. The problem is, it remains unfunded and is the "last resort" for people without health care. Their default option then becomes the hospital ER.

Emergency care providers and hospitals can ill afford to have another "public option" that does not adequately reimburse primary care physicians and specialists. Increasingly hospitals have had to make up the difference and provide financial support for emergency care providers and on call physicians. Some hospitals have closed and the number of emergency rooms has dropped nationwide as the average reimbursement continues to decrease for patients in emergency rooms.

A fifth public option is a good thing for the country - but only if more people get access to primary care. The covered services must be limited and tort reform needs to be included, because whatever form the public option takes, the benefits won't be equivalent to the best commercial insurance plans which are quite expensive in comparison. With more people covered by medical insurance, the rise in cost will be mitigated if the hospitals and health care providers don't have to factor in significant losses from uninsured and underinsured patients. There is no free lunch and no free health care.  I would appreciate hearing your thoughts and comments.

H1N1 can be spread after symptoms subside: what we need to do about it.

By Christy Palombo, RN

Seems like every day there's a new challenge concerning H1N1. For those of us in emergency medicine, it's important to take note. Is the hysteria starting? Are ER's about to be hit by an onslaught? Are people listening to us and staying home if they're ill? 

On Thursday, an article published in the Washington Post stated that people may be able to spread swine flu even after their symptoms have subsided.

This comes from a recent study of Air Force cadets who came down with the flu this summer. It was found that a large number of the cadets were still "shedding" the virus more than 24 hours after their fever and other symptoms had disappeared. You can read the full report here: American Journal of Preventive Medicine

These findings bring into question whether people are listening to what we've been telling them, most importantly, staying home if they have flu-like symptoms (such as fever, sore throat, cough, etc.) instead of going to work or school and spreading the virus to others. If transmission is still possible after symptoms have gone, it could be bad news if individuals are returning to work or school too soon.

Because of swine flu vaccine production delays, the government has backed off initial estimates that as many as 120 million vaccine doses would be available by mid-October. As of last week, only 11 million doses had been shipped to health departments, doctor's offices and other providers across the country, according to the CDC.

All of which means, unless current behavior patterns change, there will be a lot of sick people heading for their local ER.  My view is that medical professionals and the media need to get the word out to individuals and employers that staying home if you feel sick is the best medicine. It's clear that there will always be those who try to power through whatever illness they have, but it's also clear that the H1N1 pandemic is not business as usual. Behaviors need to be modified, and we need to make sure that message is getting out to the public. That's what I'm attempting to do here.

I welcome your thoughts and ideas on the topic - please ensure that your voice is heard!

Electronic Medical Records are coming to your ER. How’s your scribe program?

By Jason Ruben M.D.

Congress has dedicated 30 billion of the economic stimulus package to help physicians and hospitals create Electronic Medical Records (EMR). Those converting to electronic records can receive bonus payments from Medicare beginning in 2011, while those who haven't changed to EMR by 2015 face penalties.

So the wheels are in motion. But in an ER, Electronic Medical Records, although innovative, can be slow, time consuming and inefficient.

A study published in 2008 demonstrated that only 37% of an emergency physician's time was spent providing direct patient care - and the time dropped to 29% when EMR was implemented (Academy of Emergency Medicine 2008; 15[10]:908).

With overloaded ERs - even without the impending H1N1 pandemic - what can we do?  Start a scribe program. 

As a physician-partner with six years of experience using scribes, I've been able to help several of our ERs start their own scribe program to facilitate the adoption of EMR. In our case, an ER scribe program has not only made the change to EMR easier, but improved the quality and delivery of medical care.  This occurs because the physician is better able to concentrate on the patient encounter and spend more time at the bedside. As a result, both patient satisfaction scores and physician job satisfaction increases.

I started a scribe program at San Francisco's Seton Medical Center where I practice. The program has had a tremendous impact on the adoption of a new EMR system. Emergency physicians at Seton have the option of dictating or using the EMR. Physician performance measures greatly improved when working with a scribe.  And there was a significant increase in the use of EMR when scribes were present, resulting in significant savings in hospital transcription costs for 2008.

With a scribe program in place, the ER shifts are more enjoyable and less stressful. Rather than spending upwards of 15-30 minutes per patient toggling through drop-down menus, clicking a mouse, or marking up a smart-chart; physicians are able to spend more time at the bedside.  Scribes are trained to notify them of any ancillary studies that are done and document them as well.  Most physicians working with scribes say they are more likely to leave their shifts on-time.

Do you have a scribe program at your ER? If so, please share your comments.  If not, please respond and I can give you more reasons why I believe an ER scribe program can offer so many benefits.

The importance of innovation in the Emergency Department

By Alice Hunter, M.D.

If you remember the Beatles, you know that they were more than four guys playing rock music.  They took forms of music that had come before them and created a completely new sound that revolutionized our culture. They were true innovators.

As emergency providers, what does it mean to innovate? What kinds of innovations are needed to handle pandemics such as H1N1? How do we meet the goals of providing the finest emergency care in the future?

I believe we do this by imagining ourselves in our patients'/clients' situation and viewing our work through their eyes. This allows us to redesign our processes, adjust our roles, and improve our practices.  For example, the emergency physician Partnership that I'm a member of has implemented innovations that have resulted in decreased wait times, increased patient safety and satisfaction, and improved documentation. All have led to significant decreases in door-to-provider time and improved patient satisfaction at more than half of our Partnership sites. These innovations have created very real benefits to patients and emergency providers.

But this process has also led to innovation of another kind: the way our patients perceive us. When a patient is seen more quickly than anticipated, our empathy and commitment to delivering high-quality care becomes apparent. We're changing the perception of our patients, helping them to view us as excellent providers of emergency care.

True innovation is a result of changing our viewpoint, and being eager to imagine better ways to do things. It means always being on the lookout for the next creative idea to improve our practices.  But innovation doesn't just happen. In the case of our group, we have a committee dedicated to brainstorming and defining potential innovations. It's an open-minded forum for generating ideas that may someday inspire the next great emergency medicine breakthrough!  

Innovations come in many forms - new technologies, new methods to solve old problems, new improvements in clinical care or operational efficiencies. But the important point is that innovation needs to be encouraged and pursued in order to meet and exceed the needs of our patients now and in the future.

Is innovation a part of your group or practice? If you have any examples of how innovation has enhanced your practice, please share them.

More ER physicians are tweeting. Are you?

By Chris Hannan

Paris Hilton does it.  President Obama famously did it.

And now for an increasing number of emergency physicians, "Twitter" is becoming the technology of choice for gathering and sharing a wide variety of up-to-the-minute medical information between colleagues and even patients.  Twitter - whose 140 character format encourages brevity - enables physicians to have real-time discussions from the emergency room, or virtually anywhere.

I encourage you to read an excellent article from the Annals of Emergency Medicine http://bit.ly/jJRLp that discusses the growing uses for Twitter - and why it's fast becoming an important "tool" in the ER.  

For the uninitiated, Twitter enables physicians to communicate with colleagues and provide instant feedback on everything from emergency procedures to discussions on medical trends. Twitter allows for more transparency to what goes on in the physician's world, and enables both patients and other doctors to interact with one another in a quick, convenient way. And an important point for non-techy types, it's easy to join and easy to use.

So should medical professionals be adapting and using emerging technology such as Twitter? In my opinion, the answer is yes.

Have you gotten on the bandwagon yet? If so, how are you using it? Are you finding it beneficial? And if not, why not? I'd appreciate hearing your experiences.

Observations from an emergency physician

By Joel A. Stettner, M.D.

I have always enjoyed my 36 years in emergency medicine, and have had a stimulating parallel administrative career as well. But I now feel more than a little frustrated with what is happening in the ER and beyond.

We seem to be in an environment that does not recognize our contributions. Instead, we're hammered on a daily basis with new bureaucratic requirements, that have us looking over our shoulders for surprise inspectors on fishing expeditions, giving us little or no relief for the liability that we are required to shoulder, and increasingly devaluing our services through opaque and often unfair reimbursement policies. Let me explain...and ventilate.

I believe our specialty has always tried to wear the proverbial white hat, seeing all comers (even before EMTALA) and doing our best to effectively resolve the myriad of medical and social problems that present to us. Early on, we fought hard to establish our specialty, and then to win the often-begrudging respect of our medical staff colleagues. My concern is that our practices are now wrongly viewed as some of the most costly and inefficient, and politicians and insurers regularly batter us for this.

Of course, since EMTALA, we're federally mandated to provide care...with no assured funding, no relief from liability, and no ability to take a charitable contribution deduction or a write-off for the vast amounts of free care we provide. Don't our white hats bring any recognition other than demands for cheaper and faster care and higher patient satisfaction scores?

And those JCAHO inspections, with diligent searches for dust, unchecked boxes on our charts, and unintentional technical errors...does no good deed go unpunished? Please don't misunderstand; I support the enforcement of reasonable rules and regulations. But do the current hoop-jumping requirements make good sense?

Well, of course it's not all bad. Although we lost balance billing in California, and our state emergency services fund evaporated, we still collect from many payers, and, with luck, Medicare will give us a bit more next year. An ending recession and health care reform might also lead to more insurance coverage for our patients.

Should we try to fix some of this? Please let me know, and share your ideas as to what might work. We built the specialty; shouldn't we do all we can to protect and enhance it, for the ultimate benefit of our patients, which is where we got started?

Emergency physicians – we need your advocacy now!

By Carlos Medina, M.D.

To those of us who have been following the healthcare debate, emergency physician advocacy has never been more important. Especially with all of the disinformation and downright falsehoods flying around.

That's why I urge you to click on this ACEP link:  http://www.emergencymedicinerealities.com/

Once you're there you can use a variety of links and media options to let your colleagues, friends, and family know the realities of accessing emergency care - and the importance of ensuring that whatever healthcare reform package sees the light of day, it's reflects positively on emergency medicine.

There's also a link that let's you contact the Congress regarding emergency medicine issues. And as we know by the recent news about the healthcare overhaul, advocating for important issues about emergency medicine has never been more timely or important.

Please let me know if you have some favorite sites or links that you use for advocacy purposes. We're all in this together. And the more we communicate as emergency healthcare professionals the louder our voice will be!

Study gives emergency medicine a bad rap. Again.

By Ted Kloth, M.D.

With all the talk about healthcare reform and H1N1, it's easy to lose focus on another area that greatly affects emergency medicine: the challenge of controlling wait times and Time to Provider (TTP) for acutely ill patients. The media is rife with stories about prolonged waiting times that emergency patients have endured before being seen.

A recently published study added to this conundrum:  http://bit.ly/C3r7o.

The lead study author Leora Horwitz, MD, MHS, of Yale University and Yale-New Haven Hospital, writes that their research found that hospital emergency departments are "performing fairly poorly in seeing acutely ill patients within the time recommended by the triage nurse."  She went on to say that "...only 24.5% of emergency departments got patients needing admission admitted within four hours."(sic). This back end type of delay increases the delay at the front end for patients waiting to be seen by the emergency physician. The result can be catastrophic for the sickest patients needing the most urgent care.

I look at this and scratch my head. It's obvious that delays in care and in moving admitted patients into the hospital are connected to systemic issues. With more hospitals closing and more people using the emergency departments, it's also clear to me that as long as paradigms for seeing patients in the emergency department remain unchanged, so will the Time to Provider remain unacceptably long. So if there's an obvious performance issue, why not fix it?

Our solution was to change the paradigm. Instead of triage, we have a Provider at triage. Instead of "serial processing" of patients, we do "parallel processing". And while not every ED patient gets a bed, every patient does get appropriate care in the appropriate place in a very appropriate time period.

Under our RME (Rapid Medical Evaluation®), the treatment process is fluid and based on demand and resource availability to ensure that treatment is provided as quickly as possible. In most of our sites, patients are seen within 30 minutes of arrival, and in many sites within 20 minutes.

My ER group sees about 3 million patients per year - from small community hospitals, to trauma centers, to County Hospitals (some seeing over 10,000 patients per month -  with a Time to Provider of less than 30 minutes!). Our overall TTP is 37 minutes vs. the national average of 56 minutes (CDC data). That's about 1 million hours of decreased patient pain and suffering per year!

So, if you decrease your wait time, and the crowd follows, just think what that means for emergency patients everywhere!

I would like to hear your thoughts on the subject as well as ideas you've used to improve your ED's wait times.

Healthcare Reform? Or is it an unidentified flying object?

By Marty Ogle, M.D.

I assure you that I'm not making this up: I've just learned that more people believe in UFOs than oppose a public health insurance option. http://mediamattersaction.org/blog/200909290001

You'd never know it if you follow the U.S. Senate - who today, turned down two separate public insurance option amendments proposed by Sen. Jay Rockefeller (D-WV) and Sen. Charles Schumer (D-NY).

Rockefeller, who admitted that he knew the votes were not there for passage, aimed sharp criticism at the insurance industry-especially, he said, over their willingness to take $483 billion in new subsidies as outlined in the proposed healthcare reform bill without being asked to do much in return.

Anyone surprised? After all, the insurance industry is spending nearly $5 million per week trying to fight off health care reform. With a lobbying effort like that, why should we be surprised that real reform is looking harder to achieve??

However, outside of the Senate, and insurance company boardrooms, the support for reform including a public option is overwhelming. At least two thirds of Americans want the choice of a public plan. Fully 73% of physicians - people like us who see the need every day in our practices - want a public option http://www.moveon.org/r?r=84786&id=17382-3239975-UlDCeox&t=7

As an emergency physician, I strongly believe that an important way to ensure that our country has a strong emergency healthcare system is by supporting comprehensive health care reform that includes a public option.

ACEP has launched an unprecedented national campaign to debunk some of the key myths about healthcare reform (as it relates to emergency care) that are being perpetuated during the current federal health care reform debate. They've also outlined some of the critical problems plaguing our emergency care system, and have proposed some solutions to these problems that should be included as components of health care reform legislation. This project will be the most extensive direct communication ACEP has ever undertaken.

It's critical that we take the time to call out the major mischaracterizations of emergency care in health care reform, and propose specific solutions. To do so, CLICK HERE .  

CLICK HERE to spread the word to your friends, family and colleagues.  

The time is now to make sure our Senators are listening to the people - not health insurance companies or UFO watchers. I thank you for your support and encourage your comments.

A note on National Physician Assistant Week – October 6 thru 12.

By Ellis Weeker, M.D. 

As an emergency physician, I know the importance of an emergency department staffed with hard working, conscientious, and skilled Physician Assistants.

That's why in recognition of National Physician Assistant Week, I, along with my emergency physician Partners at CEP America would like to acknowledge the very significant contributions PAs have made - and continue to make - in our organization.  

I speak for my fellow Partners who join me in recognizing our Physician Assistants as valuable healthcare professionals and colleagues who play a vital role in providing the highest-quality care in our EDs. We couldn't do what we do without them.

So on the occasion of National Physician Assistant Week, I want to acknowledge our PAs for being the best PAs we have ever worked with - and to thank them for their continued hard work, commitment, and dedication.  Please join me in recognizing their important contributions.

A plan to prepare for H1N1 in the emergency department.

By Prentice Tom, M.D.

Flu season officially begins October 4, 2009.  With the new H1N1 virus, it is predicted that hospital emergency departments and emergency physicians could see a substantial increase in flu/flu-like illness patients. 

The CDC estimates that 40%-50% of the population may be infected by the H1N1 virus in the next two years. Regardless of the actual percentages, it is clear that emergency departments need to be ready for what could be an onslaught.  

CEP America has developed a plan to partner with our hospitals throughout the country to address the demand for emergency care resulting from a flu pandemic.  It calls for:

• Recommendations for increasing ED staffing using "phantom shifts," call back and call schedules, and phone trees.
• An evaluation/treatment algorithm based on CDC and other published guidelines, as well as links to pertinent H1N1 information websites, and an example of a patient discharge instruction sheet.
• A mechanism for employing community primary care physicians already on staff to help treat flu/flu-like illness patients in the auxiliary treatment areas on the hospital campus.

Successfully addressing prolonged ED volume surge due to a pandemic is a complex problem that requires close alignment between emergency physicians and hospitals.  Developing the ability to employ community physicians to help staff disaster treatment areas is one way we can partner with our hospitals and engage the medical community in addressing this possible crisis.

I look forward to your comments and suggestions on what your hospitals or communities are planning.

Healthcare bill sees light of day – at least for now.

By Mark Spiro, M.D.

There is a version of the much awaited healthcare bill that has finally seen the light of day this past Wednesday.  As all of us in the field of emergency medicine know, this will not be the final bill.

In a press release accompanying the unveiling of the bill, Senate Finance Committee Chairman Max Baucus says the legislation would cost $856 billion over 10 years and would not increase the deficit. The nonpartisan Congressional Budget Office, which put the bill's total cost at a lower $774 billion, says the bill would actually reduce the deficit by $49 billion between 2010 and 2019.  Of course, that's if the bill passes as is, which is unlikely.  

For those looking for the "highlights" of the bill, I found this Time/CNN page helpful http://bit.ly/T6pJD.

How might this affect Medicare you ask? Here's what Reuters has to say http://bit.ly/eol6E.

The primary question from our perspective is figuring out how healthcare reform will affect Emergency Medicine. And for right now there is no way I can intelligently do anything more than hypothesize.

The above are just a few of the online sites offering information and opinion on the healthcare reform juggernaut - and the debate will surely rage on for the remainder of the year.  As discussed in earlier blogs on this page, what we can do is to be vocal advocates for ensuring that Emergency Medicine is acknowledged as the key piece of the Patient Care Safety net.

Reform could be a good thing - and for now I am choosing to be a skeptical optimist.  As a personal opinion - which is not shared by everyone in our group - I believe some significant healthcare reform is exceedingly important for the benefit of our patients. I feel basic healthcare should be a right of all Americans (not touching the illegal alien question for now).

It's too soon to tell, but I know that as Emergency Physicians we will respond and adapt to whatever comes our way - that's who we are and what we do.   

I welcome your comments and opinions.

How much do you really know about healthcare reform?

By Marty Ogle, M.D.

As a practicing emergency department physician, I've been following the nation's healthcare reform debate very closely. I'm sure doctors, nurses and healthcare professionals in hospitals and emergency rooms throughout the country are doing the same.

While I certainly have my opinions on how I would like the healthcare reform issue to play out, I've also been taken aback by the news coverage - which has often been inflammatory at best and hysterical at its worst. Just give me the news and forget about the rant, please. What I want to know is: are we going to get healthcare reform?  And if so, what's it going to look like?

If you're as frustrated with the quality of the news coverage as I am and would like a great source of information, go online to the NPR site. It's thoughtful, unbiased and provides excellent coverage and debate. You'll find it at: http://tinyurl.com/NPRhealthcare where you'll have access to a variety of articles, a blog, and videos on everything from "what healthcare reform means to consumers" to following the healthcare debate in congress. No hysterics, just the facts.  And facts are what we need most these days.

I urge you to visit the site - and please forward any of the sites or resources that you think provide good, solid non-biased healthcare reform news. We're all in this together, so let's stay informed

Is new technology a benefit or a distraction in the hospital or ER?

By Chris Hannan

As a healthcare marketing professional, "better communication" and "technology" are certainly terms that I use every day. As a proponent of finding and leveraging better ways to communicate, I'm intrigued by how the latest communications technologies are making their way into healthcare delivery - all the way to the OR in some cases.

It's fascinating but at the same time, I wonder if we're utilizing Twitter, Facebook, YouTube and the Web etc. in ways that make sense on a business and patient-care level.

Can a web site help solve overcrowding problems in an emergency department? Some hospitals are posting their emergency room wait times on a web page. While there are many benefits to keeping the public informed - what happens if a patient shows up and has to wait 5 minutes longer than the posted wait time - does this lead to improved quality care or a better patient experience- or more stress for all involved?

Another example of new technology in the OR comes to us from Des Moines Iowa, where a 70-year-old patient's children followed her hysterectomy and uterine prolapse surgery progress via Twitter. A hospital staffer sent more than 300 tweets over more than three hours from a computer just outside the operating room. Nearly 700 people followed them. Eight people tweeted questions to the staffer. Is this a good thing, or is it just that, thanks to Twitter, it's possible to tweet about virtually anything?

What do you think about these growing trends? What kinds of technologies do you see in your ER or hospital?  Is it too much information? A fad that will pass? Or a prelude of things to come?

Technology in the emergency room: can it help physicians cope with the coming pandemic? Or hurt?

By Nancy Burghart-Hall

With the ever-increasing demands put upon this nation's emergency departments, the challenge of implementing information technology has never been greater. And the challenges will continue to grow if the  H1N1 pandemic comes to pass.

During "normal times", IT is touted to enable an ED's administrative and managerial systems to function more efficiently. In addition, software vendors tell us how  clinical applications can lead to systems that more quickly capture patients' data into an electronic medical record - including the diagnosis coding, medications, and discharge summary. However, practical experience is showing us different, and the administrative overhead added to the workload by information technology often times slows down a productive ED.

Taken a step further, what will happen during extraordinary circumstances like a natural disaster or the predicted H1N1 pandemic - both of which create an onslaught of new patients?

Will our information technologies prove themselves as useful tools to help keep emergency rooms from being overwhelmed, or will our systems be even more disruptive and clog the ED during times of stress? Will your ED be able to effectively manage a pandemic using your current IT infrastructure?

The answer is "probably not".  In which case, I have a couple of suggestions that are not necessarily "high tech" but have been shown to be helpful in expediting the online documentation and EDIS systems process.

Scribe programs:

A scribe is "a physician collaborator who fulfills the primary secretarial and non-medical functions of the busy emergency physician." Scribe programs have been shown to benefit ED doctors and their patients tremendously, expediting the ED process by as much as 30%-40%. During times of high stress, having a scribe program in place can be beneficial. For a thorough overview of how scribe programs work, visit: http://bit.ly/30wWLi 

Voice Activation:

Medical records serve many crucial purposes. Besides a description of the clinical scenario and therapy, they serve to justify care to insurance companies and managed care organizations. It's important to note that hospitals and physicians are paid not by what they do for the patient, but how well what they do is documented. Voice Activation can support the documentation process, creating a higher quality chart.

So during a pandemic, how can an emergency physician quickly generate a comprehensive, accurate and legible medical record? Both Scribes and Voice Activation are tools to help you do this.

Is your ED's IT infrastructure up to the task? I'd love to hear your thoughts and learn about the systems you have in place.  I'm also happy to share more information - just ask!

Emergency departments: prepare now for the H1N1 onslaught!

By Dan Culhane, M.D.

Is your emergency department ready for the H1N1 pandemic? It's back in the news and for most ED physicians and nurses it's most likely back in our minds. If the numbers are correct and your ED isn't prepared, this could be a very trying flu season in America.

According to a recently released presidential advisory report, The H1N1 virus could cause up to 90,000 U.S. deaths this fall - mainly among children and young adults.

The report states that the H1N1 virus, commonly known as swine flu virus, could infect between 30% and 50% of the American population during the fall and winter. They're saying 60 million to 120 million Americans could be infected, 30 million people infected but without symptoms, and up to 1.8 million Americans may be hospitalized. Visit http://www.ostp.gov/cs/hometo read the complete report.

H1N1 resurgence may happen as early as September at the beginning of the school year, and infections may peak in mid-October. However, the H1N1 vaccine isn't expected to be available until mid-October, and even then it will take several weeks for vaccinated individuals to develop immunity, the report says.

 Infections may increase as early as August as some pupils return to school, according to the Centers for Disease Control and Prevention in Atlanta.

So what does it all mean to emergency rooms across the country? We could well be seeing a huge influx of sick or "think they're sick" people. And though the report urges speedier production of the H1N1 vaccine and the availability of some doses by September, the virus will likely get to a lot of people before the vaccine does. In fact, hospitals could suffer "severe disruptions", the White House warned.

While the focus on H1N1 prevention is good, the problem is, once the media frenzy gets into high gear, it's going to cause panic - when in fact people need to exercise common sense and go to the emergency room only if they need that level of care. Otherwise, it's going to overload a system that's already overloaded.

So prepare yourself and your emergency department. Perhaps doctors need to create their own campaign around avoiding the ER - "if you're not sick, it's a lot easier to catch germs in a waiting room than if you stayed home". 

Please let me know your thoughts

Should Emergency Physicians be concerned about an H1N1 Outbreak?

By Joel A. Stettner MD.

Now that the healthcare reform discussion has taken center stage, what about the "Major Healthcare Issue" that preceded it last year?  By that I mean the novel H1N1 outbreak, more popularly known as "swine flu".

With fall quickly approaching, the issue will likely be on the front burner again. But a recent article in the Washington Post states that most Americans are not very concerned about swine flu. 

While we Americans are well known for our short attention spans, should we be more worried? Or are we too entranced by other distracting issues such as Sarah Palin and her "Death Panel"?

The CDC reports that from April 15, 2009 to July 24, 2009, there were a total of 43,771 confirmed and probable cases of novel influenza A (H1N1) infection in the U.S. Of those, 5,011 people were hospitalized and 302 people died.  

The tone of the report does not convey a sense of concern by the CDC. In fact, they have completely discontinued their confirmed and probable case counts, though aggregate national reports of hospitalizations and deaths are continuing. Their recommendations for avoiding the pitfalls of an H1N1 outbreak include avoiding sick people, washing hands frequently and covering faces with tissue when sneezing. Final recommendations on vaccination are still pending, as are details on vaccine availability.

However, the World Health Organization sees it differently. According to a recent report http://bit.ly/FYdVF the global spread of H1N1 swine flu will endanger more lives as it speeds up in the coming months. They're telling governments to boost preparations for a swift response and are predicting an explosion in case numbers.

So which is it?  Should we be concerned or should we consider the current H1N1 outbreak to be simply business as usual? My feeling is that this is a potentially serious disease (especially for the at-risk groups). I think that preparation for likely patient visit surges is very important; we must find ways to more rapidly see those with mild infections and quickly move admitted patients out of the ED. Preparation now could be critical as the traditional flu season approaches.

I look forward to your comments!

Is California’s Hospital-Based ED System eroding?

By Ellis Weeker MD.

As an Emergency Physician, I'm always looking for interesting articles about my profession. Recently, I came upon a study published by the California Healthcare Foundation. It raises the question about California's hospital-based ED system - and whether it's keeping up with the increased pressures placed upon it.  For those of us in emergency medicine, I think its great food for thought.

For the complete study, click on the link:

Is California's Hospital-Based ED System Eroding?

The study states that worsening severity of illness may be a greater factor in ED overcrowding than the growing volume of patients. My thoughts regarding their assertions include:

The supply of California ED beds grew by 17% between 2001 and 2007, while population rose 6% and ED visits increased 2%.

The supply of beds in CA EDs has risen to accommodate the increased need of an aging population as well as the increased and unmet needs for urgent and primary care. Seniors require more procedures and our system currently rewards utilization, in particular procedures. So this is not a surprise. For many hospitals, increased ED beds mean more revenue for inpatients as well as outpatients. An increase of 17% in the supply of CA ED beds can be easily explained.

A higher proportion of ED patients are more severely ill, and a greater share of visits results in hospital admission.

The higher number of critically ill and older patients greatly impacts the efficiency of an ED. More testing and therapy are required. Even after a diagnosis is made, it takes longer to admit these patients. The average percent of patients admitted to hospitals from their EDs is now 51%. So that's another reason for more ED beds.

The numbers of ED visits considered non-emergency have increased.

Lack of urgent and primary care availability to underinsured patients remains a stressor for all EDs. While non-emergency visits have increased, many insured patients have also begun to use EDs as urgent care centers.

The study reports a large variance in the percentages of increased ED visits, hospital closings and construction throughout the state. This is because our system has little or no central planning and largely responds to the local circumstances of an area, i.e. the affluence of the patients. Hospitals and their EDs close where there's poor reimbursement for patients. New hospitals and EDs are built where there's money to support them.

As always, I welcome your comments.

Physicians unite! Contact Congress now to voice your healthcare reform concerns.

By Marty Ogle M.D.

As emergency physicians and healthcare professionals, healthcare reform - whatever it ends up looking like - will affect our practice, our hospitals, and our patients.

Even though Congress is now in recess, its members are meeting with constituents around the country (as you've likely seen in the news).  Congressional leaders are also currently crafting key healthcare reform bills to be considered in September.

So now's the time to contact your Senators and Representative, letting them know your healthcare reform concerns. One of the easiest ways is to go to the MGMA Advocacy Center to tell your representatives to finally repeal the Medicare physician payment formula and tell them not to link new payment systems to this flawed update system.

It's also important to encourage them to include administrative simplification proposals to reduce costs.

While you're at it, be sure to remind them that as your elected representatives, they should not delegate authority to make important Medicare-related reforms to a non-elected entity. 

With the heated and oftentimes irrational discord going on at the moment, it's easy to lose sight of the fact that true healthcare reform is necessary, is prudent - and there are serious issues that will affect us as practicing physicians. Having your voice be heard is more important than ever right now!

Send Congress an email now and let's keep the healthcare discussion on track.  

Are the Feds about to shortchange ER care?

By David Englander, M.D.

I wanted to add my two cents to Dr. Borger's blog in the ER Forum on Tuesday re: potential funding losses to emergency health care by the Feds.

In California alone, more than 70 hospitals have closed in the past ten years due to financial pressures, even though demand for emergency care has dramatically increased.

Our state actually had the lowest national ranking (51st) in access to Emergency Care and received very low grades in other categories of the ACEP National Report Card on the State Of Emergency Medicine.

In 2003, both Democrats and Republicans came together and passed the Medicare Modernization Act (Section 1011), which included federal funding for mandated emergency care - $250 million per year to help hospitals and providers recoup a portion of the costs they incur for providing emergency medical care to patients who cannot pay their bills. This federal reimbursement has been particularly helpful to participating hospitals and providers in border states like California that are disproportionately burdened with providing care to undocumented immigrants. Unfortunately, this funding was temporary and recently expired.

Hospitals and emergency care providers should not be responsible for absorbing the costs of health care for undocumented immigrants. The federal government should bear this responsibility, as it is responsible for securing our borders.

As noted, last year the campaign to extend Section 1011 had bi-partisan support, evidenced in a May 2008 letter to legislative leaders endorsing a two-year extension of the provision under 15 signatures, including those of Barack Obama and John McCain. But that support has been supplanted by other issues.

Extending Section 1011 funding is an important issue that needs to be addressed before it "falls through the cracks". With increased overcrowding, state budget cuts (especially in California) and likely facility closures, it's impossible to believe that quality care will be there if another source of funding for hospitals and providers is withdrawn.  Our legislators need to know that this is an important issue involving a wide range of people.

To read the complete article on the topic, visit http://tinyurl.com/moos4n. For insights into ways to reach your representatives, please read a very helpful blog re: Advocacy by Carlos Medina MD. Simply click on this link:  http://www.cepamericablog.com/2009/08/be-an-advocate-get-to-know-your-legislators/

I look forward to your support and to seeing any comments you may have.

Help head off a real threat to quality emergency health care.

By Rodney Borger, M.D.

Well, the August Congressional recess has temporarily quieted the health care debate in Washington, D.C. But many doctors like me remain focused on how possible health care reform could affect our local public hospitals.

Lawmakers will soon resume the battle over how to expand coverage and how to fund it, but there is another pressing issue that doctors like me are very concerned about. It involves making sure our hospitals, doctors and nurses can continue to provide timely, quality emergency care to anyone who is admitted to one of our emergency rooms.

Right now, our ERs are in jeopardy of losing an important funding source from the federal government - funding that it has an obligation to provide.

Without the federal reimbursement that the 2003 Medicare law provides, our hospitals and health providers will simply not be able to offer the quality of care expected in our emergency rooms. That means patients will no doubt have to wait longer for treatment in increasingly overcrowded waiting rooms because of facility closures and staff and supply shortages.

Last year the campaign to extend Section 1011 had bi-partisan support. Today (a year later) I fear the issue may be overshadowed in the larger health care debate.  I'm urging our representatives to consider the consequences of halting federal reimbursement for emergency care at a time when the need for care is greater than ever.

Extending Section 1011 funding is an issue that affects everyone who works in emergency rooms as well as those who may one day need emergency care. Your help is needed. 

We need to act now! Please contact your federal representatives and urge an extension of Section 1011, so that we can continue to provide quality emergency medical care to anyone who needs it. If you have additional thoughts or suggestions, please send a comment - I'd love to hear them.

Be an advocate: get to know your legislators.

By Carlos Medina, M.D.

The old saying "if you want something bad enough just try harder" could have been coined around the topic of "advocacy". But what exactly does advocacy mean to us in the medical field? 

First of all, what we're talking about here is voicing your opinion about a particular piece of legislation that will affect what we do or where we practice - either negatively or positively.

Sounds easy enough, right? But in order to be a successful advocate for an important issue, you need to know how to monitor the legislative process and then how to gain access to your specific legislator(s) either in a letter or over the phone. Luckily, it doesn't have to be hard - especially if you follow a few simple rules.  And as we in California know first hand thanks to our recent budget woes, it really IS important to be an advocate for a position that will affect your livelihood, your hospital, and your community. And the more you write or call, the more likely legislators are to listen.

To write to your legislator, here are a few tips to follow:

• Get a grasp of the bill and your position
• Identify yourself, what you do, where you live
• Describe how the proposed legislation will affect  the community, patients and EDs
• Use local examples and refer to common interests
• Be timely and state when the bill is scheduled to be heard or voted on
• Stick to ONE subject. Be brief and to the point. Use short sentences and short paragraphs
• If calling, ask for the staffer who deals with Health Care. The key to a good relationship with the politician is through a good relationship with their staffers - they look to them for information/opinion

In addition, here are some useful links that should help you in the advocacy process:

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

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

http://www.legislature.ca.gov/ (Legislators and Districts)

Successful advocacy is important - and it's something we can all do! I'd love to hear your comments or ideas on this topic!

How the recession is affecting new graduate nurses

By Nancy Carlson, RN, MBA.

One more thing this recession has done is to temporarily mask the symptoms of a problem that's two decades old. That is, with older nurses staying in the work force longer and delaying retirement - and other nurses who left and then came back due to recessionary times - the trend toward nursing vacancies appears to have been reversed.

But there's still a nursing shortage. In fact, CINHC projects California will have a shortfall of 108,000 nurses in California alone by 2020.  So even with fewer openings, there's a real need to increase capacity to educate and prepare new nurses.

Today, the positions are being filled by experienced nurses back in the market due to the economy. The average age of an RN in California is over 47, so when they start retiring, the statewide shortage will jump. According to the California Institute for Nursing & Health Care (CINHC) 90% of RN's under the age of 55 are working, which tightens the market for new grads more than usual.

The good news is that educational capacity for RNs statewide has increased 55% since 2004, bringing younger nurses - including men - into the workforce. But despite these successes, we can't pull back in our efforts to overcome the nursing shortage.

Increasing funding for nursing-education programs is still very important. And we can't become complacent when looking at recent economic data that indicate we've solved the nursing shortage. With an aging population and continued growth in the demand for caregivers, the need for new nurse graduates is as great as ever.

So where can new graduates get the needed "first job" experience if hospitals are not hiring them? (At least until the economic tide shifts and baby boomer nurses retire).

There are nursing jobs available. Opportunities are growing in ambulatory and non-acute settings as care shifts away from hospitals. Apply for any open position, be persistent in calling employers and consider moving to states such as Texas or the Midwest with more demand. New graduates may not get their first choice of a job or location, but there are still openings.

What ideas do you have to encourage our new nurses? Should hospitals hire more staff than they really need (or can afford to have on the payroll)? What has YOUR hospital done to keep graduate nurses in the employment pipeline?

Health care reform and patient satisfaction.

By Jay Kaplan, M.D.

There's no question that in the current discussions on health care reform, pay for performance will play a central role.  Pay for care rendered is going to be replaced by pay for quality rendered. Value-Based Purchasing, the federal government's new name for pay for performance, will be tied to Core Measures for inpatient clinical quality and PQRI for outpatient clinical quality. 

Non-government insurers will follow suit, since the outcome is reduced payment to providers. CMS is already withholding payment to hospitals in some cases, and talking about reduced reimbursement for Medicare patients who return for re-admission within 30 days of discharge.  Bundled payments are also being contemplated.

A few years ago, the Hospital Consumer Assessment of Health Care Providers and Systems (HCAHPS) was created to measure the patient experience across all hospitals.  Right now, in order for hospitals to get their full Medicare market basket update yearly, they participate and publicly report their "scores".  Soon they will have to be at the 50^th percentile or have improved from the previous reporting period in order to be fully updated/reimbursed.

The three questions currently being asked about physicians are:

During your hospital stay, did doctors:

1. Treat you with courtesy and respect?
2. Listen carefully to you ?
3. Explain things in a way you could understand? 

In the early stages of nationwide implementation is the Clinician & Group Consumer Assessment of HealthCare Providers and Systems (CGCAHPS), which asks similar questions about physicians in the outpatient setting. Insurers in Massachusetts are already talking about tying outpatient reimbursement to CGCAHPS results. And don't think that we in the ED are not on the radar screen.

Now for a key point - CMS and the federal government now consider HCAHPS and CGCAHPS to be "quality" metrics. So as much as some of us would like to separate service excellence from clinical quality we and our hospitals will be paid for quality however that is defined. This means service becomes an issue with real fiscal consequences.

Rather than bellyache about an unfair system, we will need to focus on improving patient satisfaction. The good news is we can benefit from the focus on "quality", and in fact, an argument can be made that great patient satisfaction is built upon creating a great place for staff to work and for physicians to practice medicine. 

It's an approach that can work - in fact I've seen it work all over the US.

“Social media”—coming to a hospital near you!

By Chris Hannan

Technological innovations are nothing new in the medical field.  But like many other business categories these days, new technologies in the form of electronic "social media", such as blogs (like this one!), Youtube, Facebook and Twitter are becoming part of the lexicon of many hospitals and medical practioners. 

The fact is, an increasing number of people in medicine are using social networking to discuss medical topics, talk about hospitals, provide opinions, ask questions, look for jobs, keep in touch with past colleagues - you name it.  To see how, spend a few minutes with this article that discusses how many medical facilities are climbing aboard the new media bandwagon: http://tinyurl.com/caed8g

Earlier this month, Medimix International, provider of advanced marketing research solutions for the healthcare industry, released info on its recent study that shows that physicians are increasingly using social networking sites like Facebook to communicate and collaborate with their peers. It makes for some interesting reading: http://tinyurl.com/caed8g

This video, now on Youtube, was originally broadcast on ABC News. It shows doctors doing a knee replacement procedure on a woman, while also Tweeting to colleagues during the surgery in real time. Sounds hard to believe? See the video and you decide: http://abcnews.go.com/GMA/story?id=7347728&page=1

These are just a few examples of how various forms of social media are quickly becoming commonplace. While many may hear the words "social media" and think of teenagers texting away for hours, the fact is, online networking sites such as Linkedin, Facebook, and others are being used regularly by millions of professionals. And the average user age is 41 years old. So if you haven't already, you might find it interesting to get acquainted with these evolving forms of business communication. As they say, "the horse is out of the barn" - so why not climb on board and take the ride!

If you have an intriguing link about healthcare innovation-send it along - we'll share it with others here...

 

New California budget includes health cuts.

By Mark Spiro, M.D.

As an emergency physician who lives and works in California, I've been watching the never-ending budget stalemate with trepidation. Now that the plan is complete and the dust is starting to settle, it's clear that health care services will be taking a hit.

The New York Times reports that Democrats largely rejected the governor's initial plans to eliminate social safety net programs such as Healthy Families and the Children's Health Insurance Program. However, yesterday's budget plan still includes substantial funding cuts for health services. Under the agreement, the state would cut funding for Healthy Families by $144 million, which would place many eligible children on a waiting list.  Capitol Weekly reports that total funding for the program would drop by $226 million.

According to Capital Notes, legislators also agreed to cut $1.3 billion in spending from Medi-Cal, California's Medicaid program. In addition, the state's In-Home Supportive Services program stands to lose millions in state funding under the budget plan. Under the budget plan, HIV/AIDS programs also would lose a significant portion of their funding, says the San Francisco Chronicle.

It's still unclear what these cuts will mean to hospitals and health care providers on a day to day basis, but I think it's obvious that we're going to be in for an uncertain - and sometimes - wild ride.

ED Management Challenges: Lack of physician engagement and what to do about it.

By Theo Koury, M.D.

As a medical director of an emergency department, I'm faced with a variety of challenges while striving to build a successful practice. Overcoming these challenges is dependent upon one common factor: physician engagement.

Having said this, getting a group of physicians to become engaged is often a challenge. However, in order to build a prosperous and thriving practice, ensuring physician engagement must be overcome early on. So how to address a physician's lack of interest?

It's important to start with the right foundation. When hiring a new physician, it's important to set expectations early so they understand how they're expected to contribute to the practice. More importantly, you want to look for physicians who are inherently interested in being active members of a team. However, starting with a clean slate is the easy part - getting existing physicians to buy in can be harder.

As medical director, it's your responsibility to persuade your colleagues that their engagement is imperative. As basic as it seems, you may be required to point out the correlation between the success of their careers and that of the practice. In order for the practice to successfully exist, physicians need to engage their ED staff, medical staff and administration. By doing so, relationships are created that lead to cooperative efforts in solving the various patient care challenges, meeting the needs of the department, as well as creating an enjoyable work environment. Finally, one must understand that we practice in a very fluid environment. In order to keep our practice flowing in the right direction, we must remain engaged at all times and in all aspects of our practice.

As logical as all this may seem, there will always be those physicians who just won't be persuaded. Instead, other options may prove to be useful, including financial incentives. However, in the end, the medical director must make the difficult decision as to whether these inactive physicians truly fit into their practice or would be better suited elsewhere.

How do you address lack of physician engagement?

Health Care Overhaul: Real Change?

By Joel A. Stettner, M.D.

Like many of you, I continue to watch the ongoing Washington discussions on Health Care Reform with great interest. Perhaps what is most striking to me now is my feeling that an old phrase may still ring true: the more things change, the more they stay the same.

I don't mean to reject the notion of change in our system, which clearly is needed. Rather I am struck by the "politics and special interests as usual" approach that seems to have bogged down what admittedly is a complex undertaking. On the one hand, both Democrats and Republicans are holding onto their traditional and reliable positions concerning single payer and/or public option approaches, the need (or lack thereof) for medical liability reform, and the best (or least distasteful) way to fund the changes we need.

At the same time, key industry players seem to be hardening their approach, reflecting their tradition of protecting special interests. And there is risk of a new "scare tactics" campaign, raising issues around socialized medicine and pointing out how ineffectual alternative systems appear to be (Canada comes to mind, although the concept of no or badly delayed care and Canadian citizens coming across the border in droves for medical services turns out to be untrue when examined).

I cannot pretend to have good answers to the complexities of reform, but objective discussion, coupled with a long-term view towards the greater good, might help accelerate the process of finding solutions.

If you have a few minutes, check out a video created by an emergency physician in Portland, Oregon; it can be found at http://www.ourailinghealthcare.com/. I know that ER docs, like everyone else, have a point of view driven by their experiences and their needs. None-the-less, I thought this was a reasonably objective look at the problems we face, coupled with thoughtful observations about what might be worth considering as the debate goes on. What are your thoughts?

Should Emergency Physicians and Practitioners Encourage Healthier Behavior?

By Jay Kaplan, M.D. 

The nature of emergency medicine is that we give medical care to patients who present us with problems that have either arisen suddenly or are chronic conditions which suddenly worsen. 

Consequently our focus is most commonly on what we can do for the patient in that moment rather than on the long-term consequences of the illness to the patient's overall health.  What role (if any) do emergency physicians and mid-level practitioners play in encouraging healthy behavior on a more long-term basis? What role SHOULD we play?" 

When patients present to the Emergency Department there is a unique opportunity as care providers to make an intervention to help people change. They have come to us because something has happened and they feel out of control or in pain or anxious.  We're being asked for advice and are seen as experts.  Patients are more open to change at this moment when they don't feel in control. 

It's a perfect opportunity for us to play the role of expert and leverage their anxiety.

For example, the teenager who gets drunk and comes in somnolent can be counseled that he/she just put their life in danger and made a mistake and don't have to repeat this experience again. Or the smoker who develops pneumonia and is wheezing and has not yet developed emphysema can be painted the picture of needing to have oxygen in a tank to help with breathing. Then there's the middle-aged man who presents with chest pain which we determine is musculoskeletal in nature, but is also over weight and smokes and is noncompliant with his blood pressure medication.  

So yes, as emergency physicians and mid-level practioners we have a rare opportunity to educate our patients and encourage them to become healthier and prevent illness in the future. I welcome your comments.

 

San Leandro Hospital Emergency Department Closure

By Marty Ogle, M.D.

I find it pretty interesting that our representatives in Sacramento are spending their time trying to first push through a bill that would effectively delay an imminent closure of a district hospital ED and then abandon the bill and the effort to salvage the facility Oakland Tribune. It seems to me that they should consider facilitating activities to address inefficiencies and waste at the facility to make the hospital and the ED financially viable. The excuse that this is a district hospital and therefore it needn't operate efficiently is unacceptable.

There are ways to make what appears to be a financially unsound ED into one that contributes to the financial stability of the entire facility and improves service to the community. There would need to be commitment from the very top of the organization, including the five member Board of Directors, to make the changes to accomplish this, and I have seen this happen at much larger, more complex, and more challenged ED and hospitals.

It really comes down to leadership and decisiveness if this facility is going to continue to serve San Leandro. Attempting to pass bills in Sacramento to maintain the ailing status quo is not needed right now. 

I welcome other opinions on this matter. 

How to manage the daily stresses of the ED

By Ellis Weeker, M.D.

I have always found working in the ED to be a mixture of exhilaration and challenge, which creates both physical and mental stress. To deal with these stresses, I must be alert and have enough physical and mental energy for the shift ahead. The obvious is to make sure I'm prepared by getting enough sleep and rest the day before. But there are other things that are even more important.

It's important for me to arrive a few minutes early to make sure everything is ready and then "settle in" for my shift. Every ED has its peculiarities, things that come undone in the preceding shift or day. I want to make sure the back-up lists are properly posted and the things that are important to me are arranged and ready to go. Setting the ED stage and getting the proper mindset are important if I want to address the "anything-can-come-at-you" job of being an emergency physician.

During the shift I remind myself that I'm the professional on that stage. Yes. I can get upset by difficult patients, but I can't show it or let it affect my medical judgment or how I treat others. A better time to blow off steam is after the shift. Getting angry while at work diminishes my ability to manage the ED effectively.

Some patient complaints lead me to a simple solution and treatment. Others defy the combined efforts of all of the specialists on my medical staff to diagnose and treat. While the former make me feel like a genius, the latter cause me to question my competence. I find it best to be honest with these patients and myself by explaining the limitations of the ED. This also reduces the stress of the job.

Things not going well? Orders missed? Patients not undressed? Sure, these are stressors. And there are other things that get under my skin. I channel those feelings and work hard not to create stress for others. There are better ways to correct people's errors or even to acknowledge my own. I find the most effective way is to be polite and considerate. Humor is also important and goes a long way in a busy ED. The truth is that reducing stress for others allows them to work more efficiently and successfully with fewer errors.

Ultimately so much of reducing the daily stress in the ED has to do with attitude. In a busy ED the thing I have most control over is my own attitude. I choose to be positive and humble. I remind myself that this is a great job and that few other people on the planet are privileged to do so many incredible things for people's health and benefit.

Average Wait Times and Length of Stay Are Not the Whole Story

By Wesley A. Curry, M.D.

It's always of interest to read about large studies on the performance of emergency rooms that see over 120 million patients a year, and serve as the nation's health care safety net. The recent survey report from Press Ganey 2009 Emergency Department Pulse Report: Patient Perspectives on American Health Care  helps to spotlight a major concern every person has -"will I or my loved one be seen by a health care provider and treatment started in a timely manner?" The report focuses on "average wait times" but in my opinion, averages don't tell the whole story, since there is a significant disparity between emergency rooms across the nation.

Why do we dwell on the average and not the best performances and worst performance by emergency rooms across the nation? I think the public would want to know, and the news media could better serve the public by pointing out the good and the bad performers.

I agree with the conclusions of the survey, that patient satisfaction is related to the length of time patients wait to be seen in the emergency room. The CDC reported average emergency room wait times of 55 minutes in 2006. We can only presume that wait times have increased since then for 2007 and 2008. So if the average wait time to see a provider in the ER dropped only 15 minutes from that, patients across the country would save more than 30 million hours of waiting, pain, and suffering.

If the time to provider (TTP) and turn around times (TAT) for admitted and discharge patients were required reporting for emergency rooms, consumers could more easily judge which emergency room is providing timely service. These operational metrics are excellent indicators of efficiency and quality, and we know strong performance in these areas also drive market share and revenue, something every hospital is concerned about today.

For example, in our large emergency physician practice partnership - with 3 million patients in 65 hospitals across seven states - we have seen a drop of 14 minutes in the time to provider. This is 14 minutes off a time to provider which was already 15 minutes below the average wait time of 55 minutes according to the results reported in a 2006 survey by the Centers for Disease Control (CDC). This is an indicator of improved efficiencies which have greatly increased patient satisfaction.

We can no longer blame uninsured patients and lack of reimbursement for long wait times. Nor can we keep blaming the nurses or the emergency physicians and lack of staffing. What is in short supply is effective physician, nurse, and administration leadership to address emergency room overcrowding issues.

We know that using the same emergency physicians and nurses - but changing the emergency room management and patient flow systems - can transform a poorly performing emergency room into a high performing one. And it can be done without significant capital expenditures. So let's have those who have achieved exceptional performance metrics speak up and challenge the media to get the real stories out about what's working well, not just what's the "average". Patients can then make an informed choice and will vote with their feet and choose the ER that makes them wait less. And we will all be the better for it.

The Facts about Health Care Reform in the ER

By Marty Ogle, M.D.

Last week, I was reading TIME magazine's online version and came across a short piece on US Emergency Departments and how overcrowded they are. "Dog bites man", right? We all know EDs are crowded. This is NOT breaking news.

But when they spoke of the causes of ED crowding, I was impressed to see they were at least partially right about the causes: insured patients not able to get into their Primary Care Physician and sick ED patients being "boarded" in the ED for hours or days due to insufficient in-patient bed capacity.

Where the author went off track, unfortunately, was the conclusion that hospital administrators do not want to invest in the ED and instead invest in tools for high margin elective surgeries. In fact, most hospital administrators I speak with agree that Emergency Services is a profitable part of their operations. In addition, at many hospitals, the ED accounts for 50% or more of all in-patient admissions.

I am reminded that 75-90% of the patients seen in the ED are sent home. So a savvy administrator who invests in ED capacity is probably getting the most bang for the buck. The other piece to this ED capacity/crowding is what some refer to as "virtual capacity." In essence, real capacity can be altered depending upon how smoothly the place runs. Clearly, a well-functioning ED can contribute to the financial success of the hospital overall.

Finally, the author goes on to say that the impending Health Care Reform - and the possibility that healthcare coverage would be universal - will have negative effects on EDs by throwing more patients into an already overburdened Emergency Care system. I would argue that with broader coverage, patients should have greater choices and might look to other sources of care than the ED. As always, the devil is in the details. It should be quite a ride. Please let me know your thoughts.

Health Information Technology - Implications and Opportunities for ER Providers

By Nancy Burghart-Hall

The Obama Administration stimulus plan would spend $22 billion in federal and state money to jumpstart Healthcare Information Technology (HIT). And that's only round one. One of the main goals of the HIT stimulus package is to incent providers to purchase and adopt Electronic Health Records (EHR) and to facilitate the exchange of health-related information.

Hospital-based physicians are specifically excluded from these incentives, meaning no money for ER providers even if you did fund your Emergency Department Information System (EDIS). So what does this mean for emergency doctors? There are implications, and I believe opportunities to consider.

Hospitals are eligible for incentive dollars. The base for hospitals is $2 million, and monies will begin to flow as early as 2011 for hospitals with systems in place in 2010. So if your hospital has not adopted an EHR yet, you will probably feel the push soon if not already as your Hospital facility implements a system or replaces an outdated one with a certified vendor product.

To obtain incentive dollars your hospital must show "meaningful use", a term still being defined by the Office of the National Coordinator for Healthcare Information Technology (ONC). However, there is a good chance the EDIS system in your Hospital will be key since it can demonstrate orders integration, patient discharge instructions, and prescriptions. These are all part of where we see the definition of meaningful use heading. If EDIS is not at the top of the list, it may be soon.

Physician adoption of Information Technology is also part of the HIT plan, and grants will be awarded starting January 2010. This may be an opportunity for emergency doctors to support your Hospitals by leading physician adoption efforts. At many of the CEP America sites, this has already been accomplished by talented and innovative Medical Directors and site leaders.

Another consideration is the availability of information. With the widespread implementation of EHRs, information will no longer be a differentiator. Payers, providers, and patients will have more information. With the looming ICD-10 transition information to support healthcare reform, efforts will be available to CMS. It will be important to have the information others have about you and be able to continue to manage to your own performance standards. If you currently do not obtain a copy of your EDIS charts, it will be important to add this as part of every systems implementation.

For those of us in HIT for the past 20 years, our time has come. This year at the Healthcare Information and Management Systems Society (HIMSS) conference there were over 200 new HIT products and 900 new exhibitors. This is my industry's response to the stimulus plan. The HIT industry is preparing for a new wave of activity. I believe one of the primary things we can do is communicate to our stakeholders what is reasonable and doable. I'm interested in hearing any comments or questions regarding the HIT stimulus plan and how you see it impacting your emergency room.

Finding the hidden revenue in today’s emergency department.

By Ted Kloth, M.D.

In this current climate of hospitals cutting back on expenditures or shutting their doors, the burden for emergency departments to generate and capture revenue has never been greater. In my view, the revenue in the ED is there - if you know where to find it.

The easiest hidden revenue would be to capture LWBS patients. No new marketing expenditures are needed and you don't need to attract more patients (many EDs are overwhelmed as it is). You just need to make sure you see the ones that show up to your ED. That's where the Rapid Medical Evaluation (RME) system has played such an important role of garnering hidden revenue. It's a system that enables patients to be seen by an appropriate provider, in an appropriate setting usually within 30 minutes of entering the ED. And not necessarily requiring a bed for each patient.

Because the admission rate of these LWBS patients is similar to the admission rates of those seen, the big bang for the hospital comes from the increased number of in-patients and hence the increased in-patient revenue. For a hospital with 50,000 annual visits, a decrease in LWBS would increase hospital revenue by about $2 million dollars per year for every 2% of LWBS patients that are captured. So if LWBS was decreased from 5% to 1% (a very achievable result in my experience) hospital revenue would increase by about $4 million dollars per year. Allowing those LWBS patients to leave your facility untreated is tantamount to giving your competitors a $4 million dollar annual stipend - money that should have been in your revenue stream, not in theirs.

The bottom line is that by utilizing RME, we're able to see more patients per ED bed, thereby increasing patient volume capabilities and generating more revenue for the hospital. I welcome your comments or questions.

Looking Ahead – What will drive the success of the future emergency department

By Prentice Tom, M.D.

Providing emergency medical care is certainly a rewarding, yet complex and demanding business. As a practicing emergency physician for 28 years, I have seen how technological change, increasing numbers of patients (with increasing complexity), lack of treatment space and changing expectations of providers and patients contribute to an increasingly difficult and complex practice environment.

Despite the fact that the United States spends more per capita dollars on medical care than any country in the world, a substantial number of patients who seek emergency medical care still present with serious and sometimes life threatening chronic medical problems having had no or limited access to primary care.

Overcrowding of emergency departments is rampant. Ambulance diversions are common in essentially every State. I frequently read that our emergency departments are at the "breaking point." A number of recent studies have shown that hospital capacity is really the culprit, and that in-patient "boarders" are largely responsible for emergency department diversion.

Cost-efficient, quality driven emergency departments are critical to our nation's health. As an emergency physician, how can I help lead the change necessary to address the issues threatening my ability to care for patients?

Having the opportunity to help manage the largest emergency physician Partnership in the United States has helped me understand that it is only through continuous successful innovation in the practice and management of emergency medicine that we will be able to meet the needs of our patients and our communities. Certainly, there are inefficiencies in our emergency departments. For example, sequential processing of patients through a walk-in, triage, registration, waiting room, ED bed, ED nurse to ED physician algorithm is inefficient, duplicates information gathering, and delays definitive treatment. By parallel processing patients, through programs such as Rapid Medical Evaluation (RME®) and providing definitive treatment at the first point of contact, it has been shown that we can successfully reduce emergency department wait time to less than 20 minutes - frequently less time than it takes for a patient to see his/her primary care physician for a scheduled appointment.

To ensure the future success of emergency medicine, we need to continue exploring and developing innovative solutions. Programs that coordinate physician education with changes in medical knowledge, encourage physician expertise in electronic medical records and health information technology, create strong quality assurance programs, and improve in-patient throughput are all necessary for the future of emergency medicine.

I would like to understand from patients, health care providers, policy makers and those in the medical care financing industry how you view emergency medicine, and what we, as emergency physician providers can do to provide the innovation necessary to ensure our ability to provide the highest level of quality, cost-efficient emergency medical care.

Ready to hop on the Healthcare Reform Train?

By Joel A. Stettner, M.D. 

From my viewpoint, it's clear that President Obama's drive for healthcare reform is gaining momentum. I don't think a day goes by without a reminder from him or his administration that reform must be done soon in order to rescue the American economy.

For those of us practicing emergency medicine on the front lines, it's easy to see the myriad of issues that need to be addressed; ranging from providing basic insurance coverage for the millions of Americans who lack it, as well as fixing the inequities that exist almost everywhere in coverage and access.

So, a few thoughts as the train picks up both speed and passengers on its way to an unknown final destination:

Who do we trust? The "industry" has pledged 2 trillion in savings over 10 years, but I don't see how food fights can be avoided in delivering on this laudable goal. My experience suggests that the "industry" is fragmented, driven by myriad special interests, and without a universal voice backed by authority. So who carries the water for the train?

Where do we start? Healthcare is years behind other industries in adopting useful information technology. Residencies seem to be training fewer physicians in needed specialty areas. Hospitals are often at near-capacity with very few new facilities on the drawing board. And there is little coordinated effort to allocate resources even as the remaining strands of the "safety net" are unraveling. So how is the direction of our train set?

What about Medicare and Medicaid? New projections suggest "bankruptcy" within a few years, thanks to the recession and to folks who are part of my Baby Boomer generation. So these Federal programs will need to be resuscitated with taxpayer dollars, which have to come from our decimated economy. Or perhaps from future generations who hopefully will benefit from a new approach. So where do we get the financial fuel to keep the train moving?

Please don't get me wrong. I'm a firm believer in the need for reforming our creaking system. But 35 years as a practicing clinician and medical group leader have left me with a healthy dose of skepticism. I'm almost ready to get on board, but I want to be sure we stay on the tracks! I'd love to hear your opinions - pro or con!