An Emergency Medicine Success Story
While legislators, industry consultants, business analysts, health-care insurers, and more have all struggled to “fix” what’s not working with health care, recent decades have seen the emergency room being used increasingly for primary care.
Not surprisingly, physicians have some very definite ideas about what is needed to improve their systems. If you ask those who are in the trenches day in and day out, they have a pretty good handle on the real issues. As a result, emergency-department physicians in Washington and Oregon have a success story to share.
In 2012, when the State of Washington was faced with a $32 million budget deficit and “frequency of emergency-room visits” was identified as a place to look for savings, the Washington State chapter of the American College of Emergency Physicians (ACEP) rose to the occasion.
Washington State had just passed legislation that would mandate no payment for any more than three ER visits per patient for over 700 commonly-seen conditions—among them chest pain, abdominal pain, and miscarriage. Within six months the ACEP won a counter-lawsuit against the state, on the technicality that the law had been illegally passed. This legal win “hit the reset button” and gave the ACEP time to complete a plan that would reduce costs while also improving care.
ACEP leadership knew their profession could do a better job caring for patients AND save money at the same time. They had already been working towards that goal with a draft of The Seven Best Practices (see page 23) in the works. However, with an expedited deadline of three months, the ACEP set out to finalize their best practices, line up the necessary components, and start rolling the new plan out across the state.
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“We don’t need a moat in front of our EDs.
We need a back door at discharge that actually leads somewhere.”
—ALEX ROSENAU, DO, FACEP
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PROPER DIAGNOSIS
Emergency physicians knew that the ED was not the cause of high health-care costs. After all, the expensive part of health care is when patients are hospitalized. But what problems did ED best practices need to address in order to impact the state budget? Which component in the cascade of issues carried the most weight in affecting costs? Were they solving for:
Frequency of visits? First of all, it is not the most frequent visitor who is the most expensive visitor. “The homeless patients coming in from the cold for ‘three hots and a cot’ are not our most expensive patients,” explains Steve Anderson, MD, past president of the ACEP’s Washington State chapter.
Rather, he says, the patients with serious, chronic medical conditions who require lab work or radiology referrals represent the episodes that really ring up the costs. Data shows that the more expensive patients are in the five-to-15-visits-per year range, not the most frequent visitors (those in the 16-plus-visits-per-year category). So frequency alone is not the right problem to solve.
WASHINGTON STATE EMERGENCY ROOMS: Frequency of Visits
Washington State Medicaid Patients
Type of health condition? Many visitors to the ED suffer from chronic conditions that can be managed but not cured, such as CHF, COPD/asthma, chronic pain conditions, mental-health problems, or substance abuse disorders. “And when the care for these chronic conditions isn’t coordinated, we end up re-creating the wheel in the ED, repeating labs and scans that, unbeknownst to us, have recently been done by another provider,” explains Anderson.
Glitches in care coordination? In addition to those with chronic illnesses, many other visitors to the emergency room have been seen by a doctor in recent years, if not recent months or weeks. Those doctors have likely done good work in identifying a treatment plan and next steps for their patients—yet when the same patients come into the ED during a medical crisis, those treatment plans are often unknowingly left by the wayside.
Access to patient data? Most EHRs have thousands of pages of data on file, which cannot be swiftly navigated and comprehended when treating an emergency-room patient. Providers need a fast and reliable way to access the most immediately helpful data when caring for their patients in an emergency situation.
THE RIGHT DATA AT THE RIGHT TIME
Historically, physicians in the ED setting in particular have not had the patient data they need to easily coordinate care. They all have access to their health system’s EHR, which could contain thousands of pages of information about a given patient. However, more data is not necessarily the answer.
Also, while obtaining information to aid their efforts, emergency-department physicians are exempt from HIPAA regulations during the initial evaluation phase of care. Beyond that time, the broad sharing of medical information could present a privacy issue. This means that for quality care, it is imperative that EDs be able to obtain critical health information swiftly and efficiently.
The right data, retrievable in a timely manner, was the missing tool the ACEP had needed. Enter the EDIE, a software tool developed by Collective Medical and piloted through a program in Spokane. Thanks to an alliance with the ACEP, EDIE is now implemented in 100% of all Oregon and Washington EDs.
EDIE is not an EHR or a warehouse of data, but more of a data concierge that integrates with a range of leading EHRs and hospital admission, discharge, and transfer (ADT) feeds to pull out the data that has been deemed most urgent for ED providers to have at their fingertips. Drawing on multiple sources, EDIE filters the most relevant data and pushes the “only what you need” details to the surface for ED physicians.
By pulling up only the most necessary data, EDIE integrates with physicians’ workflow and eases access of information, eliminating the multiple login steps required to access separate technology systems. “For instance, taking three minutes per patient to see if they’re on a PDMP, at 30 patients per day–– that 90 minutes is not a great use of any physician’s time,” says Anderson, referencing the disparate data resources that were previously being accessed. “It might just be three clicks, but I call it ‘three clicks to crazy,’” he jokes. “With EDIE, that critical PDMP information is being pushed to me, along with additional critical medical details, on a one-page, actionable fact sheet that takes one minute to read.”
The concise template shared across all participating EDs provides the following details about a given patient:
- Demographic information
- Primary-care provider, if applicable
- Prescription Drug Monitoring Plan (PDMP) information, if applicable
- Security alerts (history of violence, attacks, etc.)
- Number of visits to the ED in Washington and Oregon in the last 12 months (where, when, and diagnoses encountered)
- Individualized care plans
- Advance directives
According to Benjamin Zaniello, MD, MPH, Chief Medical Officer of Collective Medical, “The technology is particularly powerful in complex markets, where multiple systems house the patient data that can benefit a health emergency.” As of now, the system includes a data push from variousprescription drug monitoring programs across the country. Anderson emphasizes that distinguishing “drug shoppers” from true pain patients is key to delivering the right care to these critical, but very different, high-use populations. Access to the details of a PDMP removes any chance of physician bias by providing the fact-based details of a plan already in place. “Patients with sickle-cell disease can be in a real pain crisis, and need to be cared for with appropriate meds—not treated like a potential addict,” he says. “And a possible addict needs completely different, but important, care from us.”
If a patient is under the care of a primary care provider for an existing condition, the ED providers can now access those details instantly and begin exploring what has changed to bring them to the emergency room. If this is the patient’s fifth or more visit, the system will flag them as a possible super-utilizer, and physicians can look carefully at the dates and locations of their recent ED visits.
Patterns of ED visits can give clinicians additional clues as to what may be going on with patients. If there have been frequent visits in recent months, a new health issue or complication may be emerging. Recurring visits at the same time each month could mean the patient is running out of funds for necessary medications (e.g., insulin or pain medications). If the patient’s visits are all over the place, it might look a little more like they’re shopping for pain meds and covering their tracks by avoiding a pattern.
It is imperative to success, of course, that a majority of EDs in the region be on this system, sharing information in real time. Recognizing this, the leadership of the Washington chapter of the ACEP gained critical mass by working with Collective Medical to increase system adoption. Today, all emergency rooms in Oregon and Washington are participating in the data exchange, along with a majority of ERs in California and Alaska; the system will soon be fully operational in West Virginia, New Mexico, and Massachusetts as well. Active progress towards adoption is also currently being made in over a dozen more states, such as Illinois, Michigan, New York, and Florida. The next major step will be to use the data exchange to deepen coordination with primary-care providers.
COORDINATE CARE AT BEGINNING, MIDDLE, AND END
The ED is a critical axis point in care, where a patient either gets treatment and goes home with a plan, or—should their condition warrant it—is admitted to the hospital. Considering that hospitalization is where health-care dollars really add up, it’s hard to overstate the importance of the ED’s role at that critical juncture.
“We have this concept of a case worker who assists with hospital discharge,” explains Anderson. “What if we had a case worker on the front end to help avoid hospitalization in the first place? How about we place this key role at a part of the process where it can impact costs the most?”
Many super-utilizers are simply patients who need their care better coordinated, or who have fallen off their already coordinated path. For example, 80% of super-utilizers have mental-health issues in their charts, and experience difficulty with carrying out their own care coordination. These patients, as well as those with chronic conditions, are greatly helped by consultations with case workers in the ED setting.
At the outset, a case worker can help a patient identify action items that have worked for them, plan the next steps to take, and determine specific obstacles to the coordination of their care. A concise paragraph giving an account of the ED episode is then entered into the EDIE system, to instruct future case workers or physicians in the steps being taken for that patient. Additionally, after the patient exits the emergency room, case workers can use the system to follow up and make sure the patient remains on track with their plan.
Involving case workers in the process of ED care allows some high-use patients to get back on course with an existing treatment, get home, and avoid future hospitalizations. A physician might be able to help with the immediate health crisis, but in some instances a case worker is just as important—or even more important—a contributor to the patient’s future health. Moreover, adds Anderson, the payroll expense involved in adding case management to the front stage of the ED is an expense that pays for itself in no time.
MAKE THE RIGHT CHOICE THE EASY CHOICE
By meeting the three-month deadline to implement best practices, and implementing tools to support them, Washington’s emergency departments saved the state $34 million towards the $32 million deficit for 2013. Overall ED visits were cut by 10 percent from the year before, high utilizers were reduced by 11 percent, and non-emergency visits were reduced by 14 percent. And in the midst of the prescription-addiction crisis, narcotics prescribed by Washington EDs were reduced by 24 percent.
A key component of this effort was that the best practices were supported by tools that made the workflow easier on physicians. “We made the right choice the easy choice,” says Anderson, reflecting on what it took to galvanize so many physicians towards this enormous success. The effort also incorporated a newly patient-centered view in evaluating what is best for supporting long-term care for difficult, chronic conditions.
With effort, organization, and an informed evaluation of the issues to solve, emergency physicians in Washington and Oregon saved their states money. Physicians got the tools they needed, and patients got better care instead of guarded care. It might have taken a state budget crisis to bring things to a head. But the way that crisis was tackled proved that we can’t underestimate the leadership power of physicians in overcoming health care’s challenges. And besides, we already knew physicians love solving tough problems.
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