BBI Contributing Editor
SEATTLE, Washington — Attendance was up sharply for this year's American College of Emergency Physicians (ACEP) meeting as doctors from the nation's troubled emergency departments (EDs) met to seek solutions to ED overcrowding, nursing shortages and skyrocketing malpractice insurance burdens. Two things have created this crisis: Reduced reimbursements under the flawed formulas in the 1997 Balanced Budget Amendment and the dramatic increases in malpractice insurance costs.
These problems have affected access to emergency care in many states, but attendees at ACEP said the situation is most severe in Ohio, California, Oregon, Washington, Florida, Indiana, Pennsylvania, New York, New Jersey, Mississippi, Texas and Georgia. The 1997 Balanced Budget Amendment resulted in reductions of 8% in 1998 and 1999 in spending on Centers for Medicare & Medicaid Services for Medicare patients that in turn have resulted in under-reimbursement for emergency services to such patients. Adding to these two issues has been the dramatic increase in malpractice insurance premiums for ED doctors, which in some states have reached $300,000 annually per doctor. These costs do not allow ED medicine to provide a reasonable income, particularly because of the under-reimbursement of doctors for all Medicare services they provide. Clearly, both tort reform and changes in reimbursement to cover real costs are needed to rescue the nation's emergency departments from shutdown, and they are needed now.
Data in the latest Medical Strategic Planning (Lincroft, New Jersey) market forecast for hospital emergency departments tell a similar story. In the last eight years, the number of hospitals has declined from 6,250 to fewer than 4,900, but during the same period ED visits have increased from 90.5 million a year to more than 108 million in 2001. During this same period, many nurses have left ED positions as part of the overall nursing shortage, and ED doctors in many of the states cited above have retired or changed to other areas of practice due to the malpractice/reimbursement issues. The net result is that the EDs that remain in service are severely overcrowded, resulting in delays in patients being seen and increased risk to patients once they are admitted. Moreover, even if legislation that has passed the House but is stalled in the Senate passes, it will not resolve the mismatch between demand for services and the under-staffing of the nation's emergency departments.
Even though the Department of Health and Human Services budget increased by more than $2.3 billion in 2002 to help the nation prepare for new terrorist threats, which if they occur will result in potentially thousands of patients descending on emergency departments, almost none of the increased funding is being spent to improve EDs, but is instead going to fire, police, ambulance, drugs and other stockpiles and infrastructure that also will be needed. While the government prepares for the uncertain attacks that may occur sometime in the future, it is allowing — indeed, driving — a shut-down in the emergency departments that exist in today's hospitals. Those EDs are on the critical path of every seriously injured or critically ill American and the only remaining safety net for more than 41 million Americans with no health insurance. This year's ACEP meeting was about what can be done to breathe some life into those dying EDs. While several parts of that "solution" were shown at the conference, the real question is: "Do the nation's EDs have the resources to adopt the solutions that are already available?" There is no obvious answer.
Need for information on a wider basis
The topics dealing with these issues presented at an ACEP press conference were too narrow in scope, dealing with funding of individual hospital ED services, rather than issues related to regional ED systems. This is particularly important in light of terrorist events such as 9/11. In the event that future attacks use biological agents, there needs to be a system that looks at symptoms in real-time, seen across many EDs, on a regional or national basis. The Centers for Disease Control and Prevention (Atlanta, Georgia), in a sense, is such a system, but the data flow is in no way real-time or automatic, nor are the information systems in place to provide such data. If a biological agent with a relatively long gestation period were released, the number of persons exposed to that agent by person-to-person contact could become enormous by the time the first cases began to appear in physician offices and emergency departments. The question is, once they do, how long will it take public health systems to recognize the outbreak, identify the agent and respond? Time will be of the essence in reducing needless deaths, particularly to those initially exposed.
A couple of vendors have been thinking about such problems. EM Systems (Mequon, Wisconsin) offers community-wide tracker boards that can show which hospitals are on diversion, have EDs that are shut down or other issues. While this is an excellent start, the problem is that such information is manually input on a voluntary basis by each hospital's emergency department, and often hospital administrators do not wish it to be known that their hospitals cannot accept emergency patients or are impaired in some way in delivering care. Thus, the likelihood of the information in the community tracker system being current is low.
A similar approach is being pursued with a product called Trip Wire from New Wave Software (Cincinnati, Ohio), based on an Internet-driven, Internet-accessible solution. In this concept, patient chief complaint and other selected data from a hospital's ED system would be automatically linked into the community-wide system, which would then be available to public health professionals, emergency workers, police, etc. as a management tool — helping them to spot trends in patient conditions being seen simultaneously across the community. Tripwire would then spot symptoms that are consistent with an attack and would alert connected hospitals to the agent involved, treatment, etc. — helping local healthcare workers protect themselves and make patient interventions earlier in the course of the disease.
Anything that expedites the process of caring for and documenting the care of patients in the ED will be part of the long-term solution. Computerized ED management systems are essential to any solution because they provide a level of documentation that translates into increased reimbursement and a level of supply tracking that minimizes the loss in revenues due to not being reimbursed for supplies used but never documented and billed.
The fourth annual survey by the Medical Records Institute (Newton, Massachusetts), conducted in September, makes this point emphatically. It indicates that 90% of providers recognize the need to share patient information, while 85% feel that an electronic record would improve the quality of care, and about the same number believe it would improve workflow efficiency and improve data capture. Data capture, in a properly designed system, means charge capture and increased reimbursement. Some 82% feel that a computerized medical record could reduce medical errors, improving patient safety. More than 70% believe it could provide remote access to information, a very important factor in any of the nation's emergency departments at 2 a.m., when medical records are locked down. These are just a few of the reasons why the demand for electronic patient charts will increase over the next three to five years and achieve significant penetration in hospital EDs.
The same survey identified obstacles impeding the implementation of such systems. These included 59% who indicated that funding was still a barrier. Some 35% indicated there was lack of support among the clinical staff. More than 30% indicated concern about managing the transition from paper to an electronic record, and nearly the same percentage stated difficulty with finding a single vendor solution that was not fragmented. These obstacles can be overcome with a little effort and some excellent cost studies that vendors need to provide to ED personnel.
Get ED personnel providers on board
There is one other major obstacle that the study did not identify. A growing percentage of the nation's emergency departments are staffed by ED personnel firms such as Infinity Healthcare (Mequon, Wisconsin); the Schumacher Group (Lafayette, Louisiana), serving 75 hospitals; EM Care (Dallas, Texas), serving 360 hospitals in 40 states; and Emergency Medical Consultants (Fort Worth, Texas), serving 11 hospitals — to mention but a few. These companies account for more than 500 hospitals, or about 10% of the U.S. market. Just getting the hospitals where these doctors practice to adopt ED management systems would double the number of installed systems in the market. None of these companies, or the physicians they utilize, are familiar with ED management systems, even though some handle admissions to emergency departments and bill for ED services separately. These doctors need to understand and appreciate the benefits of using ED systems and begin to pitch that as part of the quality they bring to the process. Once these doctors get on board, the resistance to using these systems could be overcome. Vendors might productively detail some of these firms to convince them, and the doctors they provide, that it is in their best interest to use these systems, particularly in terms of the enhanced reimbursement for services provided by the documentation these systems provide. It shouldn't be hard to make such a case, either — a simple thing like being able to produce the patient's chart in the ED when its needed would expedite and improve patient care.
Indeed, this is something doctors elsewhere already have figured out. The U.S. ranks 12th in use of electronic medical records, behind Sweden, the Netherlands, Denmark, the UK, Finland, Austria, Germany, Belgium, Italy, Luxembourg and Ireland. The leader, Sweden, has a 90% adoption rate of electronic medical records, according to a Harris Interactive survey. The U.S. ranks in the bottom third of the survey, ranking ahead of countries such as Greece, France, Portugal and Spain. It is past time for American physicians to get automated, and past time for vendors of American ED management systems to fix their products, overcome the sales objectives and sell some systems.
Unfortunately, some vendors of ED documentation systems are selling unsafe products. As we have done for the last few years in reviewing ED products on the exhibit floor, we deliberately entered bogus values for basic vital signs such as blood pressure — and far too many of these systems accepted the incorrect, clinically dangerous values. No system should allow entry of diastolic blood pressure values that are higher than systolic, or ridiculous values like 575/15, but many do. With HL7 interfaces to monitors available now for several years, there is no excuse for systems that don't pick up this data directly from the monitors. Yet some vendors haven't gotten around to these interfaces and would rather require the busy ED doctor or nurse to manually enter data that is being automatically collected by the device attached to the patient. These are the details that physicians notice, just as we did, but may not mention to vendors as they walk away from the booths, shaking their heads over the lack of progress in addressing basic work-flow efficiency and patient safety aspects of available systems.
On the positive side, typed or computer-generated notes take 11 seconds (on average) less time to read than written notes, yet many hospitals still allow hand-written notes. These hospitals have 25% of records that are either difficult to read or unreadable, according to Francis Coughlin Jr. MD, a cardiovascular surgeon and legal consultant. He said that ED docs who end up in lawsuits with such records lose. Average awards for losing now are in excess of $1 million, and that drives up everyone's malpractice insurance rates as insurers raise rates to cover the amounts being awarded. Electronic nurse and physician charting in the ED helps to eliminate such issues by providing a legible, more consistent chart for each patient, or even documenting adherence to a "best practices, protocol-driven" approach to patient care. Such records also reduce the $7 to $14 per patient cost of transcription to $2.50 to $4 per patient, which is a significant savings if multiplied by 108 million patients in U.S. hospital EDs.
Pieces of the solution are available
There were many vendors of computerized pieces of this solution at ACEP and a few vendors of entire ED management systems. The vendors of part of the solution offered computerized ED tracker boards, which are essential in the busy emergency department for the staff to track who the patients are, where they are, what is being done to them, what needs to be done next and who needs to do it. While most of these tracker board systems work reasonably well, the problem is that automating the tracker boards is only a small part of solving the total problem. It also is necessary to automate patient admission, triage, nursing notes, physician notes, orders, test results and billing. Systems that do this are ED management systems, and vendors offering these systems also were at ACEP. Companies offering ED management systems include established competitors such as Wellsoft (Somerset, New Jersey), with eight sites live, and newcomers including T-System (Dallas, Texas). Other vendors on the ACEP exhibit floor included New Wave Software, ePowerDoc (Estes Park, Colorado), HAS Solutions (Pymble, Australia), A4 Health Systems (formerly Nine Rivers; Cary, North Carolina), MedHost (Addison, Texas) and Xpress Charts (Jacksonville, Florida). The newcomer to watch in this space is the Aussie firm HAS Solutions, which will not begin marketing in the U.S. until next year but has a large number of systems installed and running in Australian hospitals, according to the company's booth personnel.
These systems use a variety of computing platform approaches, from local server to web-based, from Windows 2000 server to Sybase and Oracle on Unix-based servers. The majority of these suppliers have 20 or fewer systems installed, although those who started selling tracker systems may have many more using their tracker system who have not yet enhanced their systems to support charting, orders, billing, pharmacy, triage, coding and other ED management system functions.
Many of the newcomers are ED form companies that have grown up. T-System, for example, is the largest ED forms company, providing forms used by more than 1,500 U.S. hospitals. The development of its excellent ED management product started by the computerization of these forms. Of the many systems we looked at on the exhibit floor, T-System did the best job in streamlining the workflow associated with generating the documentation, with a number of important and useful functions, including the ability to generate both a written record and a set of patient discharge notes automatically for each test, treatment and drug involved. The company should have little difficulty converting many of its paper-based forms clients into computerized ED management clients over the next couple of year, assuming EDs can find the capital funds required to make the needed technology investments.
Other excellent systems we saw included Wellsoft's product, GE Medical's (Waukesha, Wisconsin) Centricity system and Philips Medical Systems' (Andover, Massachusetts) OEM system from Ibex Healthdata Systems (Rosemont, Illinois). Each of these was well designed, well implemented and suitable as a T-System alternative. Some products, such as the GE Centricity and Philips' OEM Ibex, had the ability to interface to their own and other vendors' vital signs monitors — an advantage for providing a continuous patient record of time spent in the ED environment. This can be essential, as some patients are spending hours in ED environments, even after they have received initial treatment and been admitted to the hospital, because often the hospital does not have enough staffed beds due to the nursing shortage. As a result, patients may spend hours — sometimes a nursing shift or more — lying on stretchers in hallways waiting for beds to become available. This is a lamentable environment to be in, as the pace in the ED is hectic, the backlog continuous, and the potential to get lost or ignored very great for patients spending extended periods in there. A continuous record of vital signs therefore becomes an important indicator of the care provided. This is also where a tracker status board and patient locator badge can be helpful in continuing to remind the staff that a patient is still in the ED and needs to be looked in on from hour to hour.
One implication of this warehousing of sick patients on stretchers in the ED is the need for wirelessly networked portable patient monitors. Units such as the Welch Allyn (Beaverton, Oregon) Propaq, with its six hours of battery operating time and built-in ISM band wireless networking, are ideal answers. So are Passport monitors available from Datascope (Mahwah, New Jersey) or Escort monitors available from Medical Data Electronics (Arleta, California). These larger portable monitors are better solutions than smaller, patient-worn transmitters, because they have a waveform display that the staff can use at the stretcher, without having to carry around a separate display device. Clearly, any system designed to serve the ED should be able to support both wireless and cabled local area network monitors from throughout the ED to accommodate the overcrowding that is now increasingly the rule rather than the exception.
This is the situation that prompts a hospital's ED to divert patients to other hospitals, which in turn can create problems elsewhere. The target hospital has no advance notice and is not staffed to handle the sudden stream of diverted patients. Some vendors are taking advantage of this community-wide need, by establishing web-based community hospital "status" tracker products, where each hospital can see the status of the ED facilities of other hospitals — whether they continue to be able to accept patients, or are about to begin diverting them, or are already diverting them. These boards also can indicate the level of certain key items a hospital may need, such as specific drugs or supplies on hand. This is useful on a day-to-day basis, but becomes essential during an event like a flood, earthquake or terrorist attack with biological or chemical agents.
One vendor offering a voluntary solution for this need is Emergency Visions (Smyrna, Georgia). It offers a set of software tools that leverage the web — EmergiVision and ResponseVision, as well as consulting services that can track status on a community-wide basis. Again, funding for such resources remains the key question.
(Next month: More from the ACEP exhbit floor.)