A regulator, Harvard prof. walk into an ER ...

By Anthony Brino
08:14 AM

Between the health reform’s goal of avoiding acute hospitalizations, the rise of urgent care clinics and the new possibilities of digital health, emergency rooms are poised for transformation. Indeed, a much needed one.

Federal and state regulators, medical professors and experts of all sorts have a lot of ideas and initiatives aimed at preventing ER-based treatment of uncontrolled chronic conditions like diabetes and heart disease — by nipping the problems that would lead to an emergency in the first place — as well improving the ER experience for those who do need to use emergency care.

For some, the ER is a stark reminder of why “patient-centered” healthcare is now a much-heralded mantra. As recent experiences by prominent health professionals show, an ER visit can bring to mind long waits for a cable guy that may never show, lost baggage and flight delays, plus physical pain and of course a lot of money spent.

“There’s just something about being boarded on a gurney in a hospital hallway for fifteen hours that gets one thinking about paradigm shifts,” as Charlotte Yeh, MD, a trained emergency care physician and the chief medical officer for AARP Services, wrote in Health Affairs describing her ER and hospital stay after being struck by a car.

 

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More views on ER came recently one summer evening from Niall Brennan, the Centers for Medicare & Medicaid Services’ director of information products and analytics, as he entered Johns Hopkins Medicine’s Suburban Hospital, for what would be the first of two ER visits in 36 hours.

While Brennan did not want to elaborate on his experience and it would not be appropriate to pry, his public comments do suggest that, if not Byzantine per se, the American ER is an area of healthcare with a lot of room for improvement, despite the good intentions of doctors, nurses and administrators, the investments in comprehensive electronic health records, and attempts at quality measurement.

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There may not be a quality metric for time spent waiting for an empty IV line to be removed, but there are metrics for ER care and they may not always work well, argues Ashish Jha, MD, a practicing internist and Harvard health policy researcher.

Last August, Jha was rollerblading along the Shining Sea Bikeway, in Falmouth, Massachusetts, when he hit a tree root, “went flying” and landed on his left shoulder.

“I could tell immediately that something was wrong — I couldn’t move my arm and was in the worst pain of my life. (It) was obvious that I had dislocated it,” Jah wrote on his blog. “What happened next was that I received some of the best care of my life – unfortunately it was not from our healthcare system.”

Lots of people stopped to offer help. A pediatric nephrologist who happened to be passing offered to pop his shoulder back into place, which Jha declined. He eventually accepted a ride to Falmouth Hospital from a couple riding a tandem recumbent bike.

“We finally made it to the ER," he wrote, "and, ironically, it was then that my care stopped being so wonderful.”

It started off well enough – a triage nurse saw me walking in holding my arm, in distress. She got me a wheelchair and brought me into triage. I explained what happened, gave my name, date of birth and described the pain as the worst of my life. I was then shuttled to registration, where I was asked to repeat all the same information. It felt surreal: I had moved all of 10 feet and yet somehow my information hadn’t followed me. The registration person asked me question after question. Initially, the same ones: name, address, phone #, etc. Then, my Social Security number (presumably so they could go after me if I didn’t pay my bill), my primary care physician’s name, his address, his phone #, my insurance status, my insurance #, my insurance card, my emergency contact, their address and phone #, etc. etc. etc. I told her I was in excruciating pain and needed help. A few more questions, she said. She needed the complete registration

Jha was placed in the radiology department to wait for an x-ray — “for what felt like forever.” Groaning in pain, half a dozen staffers passed him, avoiding eye contact it seemed. He asked one passerby for help, and she went to prod an x-ray technologist, who “was the first to acknowledge that my arm looked painful,” Jha wrote.

One measure of quality for emergency care of bone fractures is how many patients receive pain medications within an hour, Jha notes. His dislocated shoulder wasn’t a fracture, but it’s a relatively apt comparison — and the measure is also dubious. “While I don’t know who came up with 60 minutes, it wasn’t anyone with first-hand experience sitting in a waiting room in excruciating pain,” he wrote.

It was not until he saw an emergency doc that he received morphine. He then got his shoulder popped back in place and the rest of this visit and recovery went relatively smoothly. But he was left with a window into the healthcare system that should be food for thought for people working on designing, implementing and tracking health reform.

We have a lousy system. There were so many reminders in my short visit to the ER. Asking someone in excruciating pain to repeat demographic information and wait for their insurance information to come up on the computer? Even when I pleaded with her, she blew it off, reassuring me insurance information was important.  Because that’s how we do business in healthcare. Making sure I was insured was much more important than making sure I was treated quickly ... We can’t design a system where some of the information is obtained when the pain is better? There was no way to take my credit card as collateral and let me go on my way? Can we really not design a better flow so that patients with severe pain get relief without waiting needlessly? There were so many little opportunities to make my process faster, but it was clear that there was no reason for the hospital to invest in those changes. No one holds them accountable. In most industries, the payer holds the provider of poor services accountable. Not in healthcare.

Indeed, many quality measures are ripe for change, and the ER is one place to start. “Meaningful quality measures increasingly need to transition from setting-specific, narrow snapshots ... to assessments that are broad based, meaningful, and patient centered,” as CMS chief medical officer Patrick Conway wrote last year.

Charlotte Yeh, the emergency physician who was hit by a car, said she “felt processed and disengaged” during her ER and hospital stay.

“I was struck by the uneven nature of my care, marked by an overreliance on testing and a narrow focus on limited quality metrics such as pain management or catheter care processes,” wrote Yeh. “The unintended consequence of our current approach is that the clinical measure can become more important than the patient. I am afraid that as a result, we may be training a new generation of practitioners to equate high-quality care with conducting a test.”

During her four-day hospital stay, Yeh noticed that no one had ever asked her how she was doing, if she needed anything or had concerns. She did have concerns, previously asking for a physical exam of her knee as it was swelling, but that only came belatedly.

“This is disconcerting, especially at a time when patient-centered care — that is, care delivered with me, not to me or for me — is becoming the new normal,” Yeh wrote.