Emergency department leaders know that in today's healthcare reform environment, capital requests for emergency department expansions die quickly and are buried with sermons about primary care medical homes, population health management, accountable-care organizations and multi-use ambulatory centers. In the era of reform, emergency departments have suddenly gone from pivotal to passé; from conferring bragging rights on hospital leadership: "we have the busiest emergency department in the state" to being considered costly, and antithetical to reform's push to move care as close to the home as possible. But a new study, published in May by the RAND corporation, titled "The Evolving Role of Emergency Departments in the United States,"challenges us to re-think the value of emergency departments today, and to re-envision the role of such departments tomorrow. The study, based upon physician-interviews and an analysis of publicly available data provided by the CDC, the Agency for Healthcare Research and Quality and the Robert Wood Johnson Foundation, found that:
- Hospitals rely on emergency departments for almost all their admission growth and a substantial portion of their revenues, suggesting that efforts to shrink emergency department volume will hurt hospitals financially.
- Emergency departments serve as the solution to a fundamental lack of access to care in the U.S, suggesting that without emergency departments the existing poor access could become catastrophic.
- Primary care physicians rely on emergency departments to perform complex diagnostic testing and to facilitate admissions, suggesting that emergency departments serve as an extension of primary care and a solution to the bureaucracy of the hospital admission process.
- Most patients who visit emergency departments don’t do so for convenience. They visit the emergency department because they believe they have a serious condition or they are sent there by their physician, suggesting that contrary to widely-held beliefs people do not deliberately misuse emergency departments. It also introduces the idea of an alternative definition for what constitutes an "appropriate visit," a definition determined as much by patients and their primary care doctors as by emergency departments.
The authors argue that these results show emergency departments play a much bigger role than we realize. To me, this study also challenges us to be open to a possible new model for the emergency department of the future; a model in which emergency departments expand instead of shrinking; a model in which emergency departments are the cornerstone of efforts to reduce the costly, fragmented care in the U.S; a model in which we leverage emergency departments' 24/7 access to all instead of lamenting it; and a model in which we reduce emergency department costs for non-emergency patients instead of reducing patient access. This model could include same-day urgent care, and primary care, for patients without ready access to a primary care physician. It could also include much better "observation" services for patients being monitored pending a decision to admit, which would help decrease inappropriate admissions. Finally, the emergency department could provide initial population health management services to prevent unnecessary repeat emergency department visits and hospital readmissions resulting from suboptimal care in the community. For all this to occur, hospitals would have to dramatically change today's emergency department model. This would include expanding the traditional emergency department staffing model to include primary care physicians, hospitalists and care managers. It would include constructing emergency department facilities with dedicated primary and urgent care facilities within the same footprint. It would include building emergency department observation units of adequate size and staffing to accommodate large numbers of patients. It would include training emergency department physicians and other staff for an expanded role that integrates inpatient and outpatient care. It would include allocating emergency department costs differently so that non-emergency conditions are priced reasonably. And finally it would include converting the siloed emergency department information systems of today into mini health information exchanges that would serve as a nexus for the sharing of inpatient and outpatient information.
It's easy to dismiss this model as unworkable or even crazy. Fears will undoubtedly include that primary care physicians will object to perceived competition; emergency departments will become backlogged with non-emergency patients; non-paying patients will increase; and emergency departments will experience skyrocketing costs. But we should at least consider it. After all it was only 16 years ago that many said the hospitalist movement — physicians dedicated solely to inpatient care — was a misguided fad that threatened continuity and quality of patient care. Today hospitalists, who number 30,000 nationwide, are considered essential by physicians and hospitals alike, and are viewed as critical to improving hospital quality.
So, to the hospital CFOs: Don't put away your wallets yet. There may be another round of emergency department expansions on the horizon.
Dr. Andrew Agwunobi is a leader of the Hospital Performance Improvement practice at Berkeley Research Group. Prior to joining BRG, Dr. Agwunobi served as chief executive of Providence Healthcare, a five-hospital region of Providence Health & Services in Spokane, Wash. He previously held the positions of president and CEO of Grady Health System in Atlanta; president and CEO of Tenet South Fulton Hospital in East Point, Ga.; COO of 14-hospital St. Joseph Health System in California; and secretary of the Florida Agency for Health Care Administration. Dr. Agwunobi has also served as chief of the Main Pediatric Urgent-Care Department for Harvard Vanguard Medical Associates in Boston. A board-certified pediatrician, Dr. Agwunobi received a master of business administration from the Stanford Graduate School of Business.
More Articles on Emergency Department Operations:
The Emergency Department: The Nexus of Healthcare
A View of the ED's Integral Role within the Bigger Facility Operations Picture