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Keeping routine medical care out of hospital emergency rooms

By Jennifer Brokaw
Tuesday, May 18, 2010; A19

When health-care reform legislation was passed, many assumed that it would relieve some of the pressure on hospital emergency rooms, which for decades have served as doctors' offices for the uninsured. But if the new law is not coupled with an ambitious plan to deliver care to the newly insured, the ER will continue to be the first place many seek care.

Solving the problem of access to care will require new thinking about how to meet all patients' needs, and the first step should be rethinking the role of emergency rooms.

It is not news that crowded conditions and long waits are staples of most emergency rooms in the United States. Many hospitals have been forced to send incoming ambulances elsewhere because of crowding. So it's clear that an influx of patients seeking help for non-emergencies -- a sprained ankle or seasonal allergies -- could further impair the ability to care for the critically ill or injured.

This appears to be what occurred after universal coverage was enacted in 2006 in Massachusetts, where ER visits increased by 7 percent, with costs rising 17 percent. It could be that the newly insured were accustomed to going to emergency rooms for treatment.

Adding patients to the ER in this way is simply not cost-effective. ER doctors rarely have relationships with the patients we see, and we don't have time for a lengthy dialogue about their ailments. So we often order expensive tests that add to a hospital's already-high fixed costs. As a result non-emergency care delivered in the ER costs almost five times more than in a doctor's office or clinic.

There are four ways we can steer minor emergencies away from the ER.

First, establish more offices and clinics that are not based in hospitals (and do not carry hospital overhead). The recent trend toward low-cost, retail- and pharmacy-based clinics has been a relative success for what these facilities offer: quick evaluation and treatment for simple problems. They have been found to cost less than one-fifth of what an ER costs for the same complaint.

Second, invest in allied professionals and paraprofessionals such as nurse practitioners, physician assistants and medical technicians to deliver much of this basic care. Training more primary-care physicians will not be enough.

Third, improve systems related to the delivery of health care. Every well-run company knows its supply and delivery chain in detail, so why don't health systems? Managed health-care systems such as Kaiser Permanente and the Mayo Clinic are ahead of the curve in this

respect.

Every municipality or county should have a detailed understanding of where needs are and a plan to address them. For example, by knowing the exact numbers of diabetics, smokers, and people with kidney disease and high blood pressure in our communities, we can predict how many CT scanners or, say, vascular surgeons are needed. Gaining this knowledge will require cooperation and information-sharing among all health-care entities: insurers, hospital systems (both public and private) and managed-care systems.

Finally, we need to employ the new ideas and technologies that have emerged from the Internet and social networking revolution to link patients with informed advice about their conditions. In a fully realized online system, simple medical questions can be answered by health advisers in real time. Patients can be directed to walk-in clinics, urgent-care centers or even emergency rooms when necessary.

Emergency rooms will always be open to those who have nowhere else to go and those who have worrisome symptoms that turn out to be minor issues. And some will argue that there is little marginal or additional cost to using existing ERs to accommodate the new

wave of patients. But to deliver the best-quality care to the most people, we have to commit to a new workforce and a new set of tools and thinking.

We have grown accustomed to allowing ERs to accommodate poor planning. Let's save emergency rooms for real emergencies such as motor vehicle accidents, heart attacks, stroke or severe infections.

That alone would be laudable

progress.

The writer is an emergency physician in

San Francisco.

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