The emergency department sits at the crossroads of outpatient and inpatient medicine. However, the unsubstantiated perception is that many who go to the ED are misusing this resource. EDs are frequently described as expensive and often the target of public health officials trying to reduce utilization. Nonetheless, studies show that emergency care accounts for about 6% of all healthcare expenditures. It is time we flip this narrative. In this era of healthcare transformation, the ED is playing an important role in providing the triple aim of reducing costs, enhancing quality and the patient experience, and improving population health.
Reducing costs: While often misunderstood as a major cost driver in medicine, emergency care can have a major effect on cost savings. It's true that EDs account for nearly two-thirds of hospital admissions and more than 80% of unscheduled admissions; therefore, they are the gateway to some of the most expensive care. But it's the top 5% of patients, the so called super-utilizers, who represent 50% of healthcare costs overall. Much can be attributed to their frequent visits to the ED. But many health systems have gone to great lengths to reduce utilization among these groups and thus slash costs. The most successful programs focus on the ED and concentrate ancillary resources on these patients, helping to avoid preventable admissions.
Some locales have begun to engage the emergency-care community by working with EMS systems to visit, treat, and—as often as possible—avoid unnecessary transport to the ED. These coordinated-care systems often include live audio or video connections with emergency medicine physicians providing medical direction. Increased use of ED observation units (which are short-stay admission units run by emergency personnel), helps to decrease costs by reducing utilization, hospital lengths of stay, readmission penalties and the conversion rate of observation to inpatient stay. These units have been so successful that over the past 10 years many hospitals have now opened 30- to 40-bed observation units.
Improving quality and the patient experience: The early diagnosis and management of emergent conditions will always be the focus in the ED, but there are many new frontiers in which facilities have begun to work within the system to increase the quality of care. The most obvious way is to work more collaboratively with primary-care providers.
One example has been our work with a local accountable care organization where we collaborate with primary-care physicians on all ED visits by their patients and pair these encounters with next-day appointments. Coordinated-care programs for specific conditions that involve the whole spectrum of care—from ED arrival to after discharge—help improve overall care. Their timely initiation has been shown to lead to better outcomes.
Many of these coordinated-care plans involve observation admissions to ED observation units where standardization of care through collaboratively developed accelerated diagnostic protocols improve outcomes. Some EDs, including mine, have begun to engage the urgent-care and retail-care providers to offer quality oversight, provider education and enhanced coordination through integrated referral systems.
Improving population health: Contrary to the hopes of many, healthcare reform has done little to stem the tide of increasing ED visits; in fact the reverse has been true. In many cases, expanded access to healthcare has led to increases in ED visits of equal if not greater acuity. The ED can and will continue to improve population health by being the safety net for all individuals while also often being the access point for the uninsured, underinsured and newly insured. However, EDs can also be a focal point of access to healthcare beyond the emergency visit. Programs like ED-based telehealth, paramedicine in rural communities and referral to preventive health programs are a few examples of improving population health through programs initiated in the ED.
EDs, just like our healthcare system, are evolving and so should our viewpoint of their role in healthcare reform. The ED should no longer be viewed only as an expensive venue for care. It should be viewed as an opportunity to engage patients by providing the range of resources a healthcare institution has available. These innovative and integrative models involving and/or stemming from the ED bring us closer to achieving that elusive triple aim.
Dr. Anthony Napoli is chairman and medical director of the emergency department at Newport (R.I.) Hospital.
