stop the war on the emergency room (fix the system failure)

There’s a war being waged on one of America’s most revered institutions, the Emergency Room. The ER, or Emergency Department (ED for the sake of this post) has been the subject of at least a dozen primetime TV shows. What’s not to love about a place where both Doogie Houser and George Clooney worked?

Every new parent in the world knows three different ways to get to the closest ED. It’s the place we all know we can go, no matter what, when we are feeling our worst. And yet, we’re not supposed to go there. Unless we are. But you know, don’t really go.

Somehow, we’ve turned the ED into this sacrosanct place where arriving by ambulance is ok, and all others are deemed worthy based on their insurance rather than acuity. If you think I’m wrong, ask any ED director if they want to lose 25% of their Blue Cross Blue Shield volume.

But its true. I hear ED physicians openly express disappointment in people who came into the ED and shouldn’t have. It’s just a stomach bug, you shouldn’t be here for this… Or, it’s not my job to fill your prescriptions…

Today, NPR’s Julie Rovner published a synopsis of recent findings from Oregon’s Medicaid expansion and its effect on ED use:

“Medicaid coverage increases emergency department use, both overall and for a broad range of types of visits, conditions, and subpopulations,” says Amy Finkelstein, an economics professor at MIT and one of the authors of the study. “Including visits for conditions that may be most readily treatable in primary care settings.”

“When you make ER care free to people, they consume more of it. They consume 40 percent more of it,” says Michael Cannon, head of health policy for the libertarian Cato Institute. “Even as they’re consuming more preventive care. And so one of the main arguments for how Obamacare was going to reduce health care costs is just flat out false.”

Some history

The Emergency Department is a fairly modern invention. The first EDs were born of two separate, though similar, aims. At Johns Hopkins, the ED began as the accident room, place where physicians could assess and treat —wait for it —minor accidents.

Elsewhere, in Pontiac Michigan and Northern Virginia early EDs were modeled after army M.A.S.H. field hospitals. They were serving more acute needs.

Today, billing for emergency department visits is done on the E&M Levels where level 1 is the least acute (think removing a splinter) and level 6 is traumatic life saving measures requiring hospitalization (think very bad car wreck). Most EDs, and CMS auditors, look for a bell curve distribution, which means there are more level 3 and 4 incidents than most others. While coding is unfortunately subjective, solid examples of level 3 visits include stomach bugs requiring IV fluids, a cut requiring stitches, and treatment of a migraine headache.

What’s my point?

  • Most EDs treat minor needs.
  • There is historical precedent for treating minor needs (accidents).
  • Over use is a concocted problem resulting from a red herring of cost and thinly veiled desire to keep lower paying plans and less compliant patients out of the high profit ED.

There, I said it.

What the Oregon study tells me is that the ED represents a clear desire path for consumers. Healthcare economist Austin Frakt put it well in his reaction:

Ultimately, my view is that “overuse” of the ED reflects the broader problem that the health system is not very responsive to consumer demand or sensitive to all types of consumers. (The disparities literature is relevant here.) In other words, it’s not consumers making “bad” choices, but the system offering poor ones.

The ED is convenient, it’s open 24 hours, it does not require an appointment. So when the stomach bug or kitchen accident gets the best of you at 9:00 PM, and your doctor’s office is closed, where are you going to go? And, yet, we still chide people —via reporting, casual comments and the communication of health systems —for using the ED for “non-emergent” needs.

Who determines what is emergent? But I digress…

What I’d like to see is more hospitals flinging open the doors of their EDs and saying, *we’ll take you, any time, for any reason, and you won’t wait long or pay an arm and a leg…"

Sure, we need to acknowledge that the ED is probably not the best place for primary care. But, whats a body supposed to do when their primary care office has a 3 day wait and is closed at 9 PM? Tackle that system problem, and I’ll sing a different tune.

A few years ago, while working for a large hospital, I was part of a team exploring an expansion into urgent care. Urgent care, as the name implies, is like emergency care, only…you know…less emergent and more urgent. We wanted to offload some of the lower acuity visits from the ED, but didn’t want to lose the volume. Urgent care made sense. So where do we put it? Well, on the campus of the hospital was ideal, it had the benefit of being able to turf people out one door, across the parking lot and into the urgent care. But that required new or repurposed space, which is expensive.

What, in fact, made the most sense was to make the urgent care part of the ED itself. In other words, have a bargain sale isle in the ED. You do that by staffing differently, ordering fewer tests, and generally charging less. Which is where the conversations ended.

But, I still think that’s a viable solution. Rather than continuing to wage war on the poor ED, we need to build EDs which are capable and cost effective at caring for every need which walks in the door. That includes being timely, compassionate, participatory, and affordable. It requires being connected via EMR to primary care offices. And, above all, it means listening to the desires of communities who have a need for the 24-hour, walk in care option.

From Elsewhere: more on the need to embrace millennials and start-up culture

I’ve written before about the changing workforce and my concerns about healthcare’s readiness to accept those changes. This week, Tom Agan (from Riva) writes in The New York Times about Embracing the Millennials’ Mind-Set at Work:

To compete for the best millennial talent, companies are having to change in fundamental ways. …
Goldman made the change partly because it was losing millennials to start-ups. But start-ups typically offer less pay and equally long hours, which suggests that providing more time off isn’t the only answer. If corporate cultures don’t align with the transparency, free flow of information, and inclusiveness that millennials highly value — and that are also essential for learning and successful innovation — the competitiveness of many established businesses will suffer.

Anecdotal though it may be, I’m seeing a trend in healthcare. Fewer and fewer bright young people are queuing up for the dark suit, long hour, old white men’s club of hospital administration. Instead they go to work for a healthcare startup, or other unexpected players like Walgreens, Target or SG2.

In short, I’m worried we’re facing something akin to a brain drain in traditional healthcare —an energy drain. We’re notoriously slow to change, particularly when it comes to culture. Paternalism is as strong in administration as it is in clinical care.

How do we get hip?

  • Embrace – Tom Agan suggests: “…rather than complaining, it’s time to embrace millennials for what they can offer, to add experience from older workers to the mix, and to watch innovation explode”
  • Launch a skunk works – the term skunk works* comes from of Lockheed Martin’s advanced development programs. The idea is a start-up inside a traditional company. What if hospitals offered millennials and others the opportunity to experience start-up culture?
  • Try Google’s 20% rule – Google’s famed 20% rule was the catalyst behind gmail. Googlers are encouraged, in some cases required, to spend 20% of their time working on a project unrelated to their core job. Can you imagine if health systems encouraged the same kind of time sharing?

*Via Wikipedia:

The designation “skunk works”, or “skunkworks”, is widely used in business, engineering, and technical fields to describe a group within an organization given a high degree of autonomy and unhampered by bureaucracy, tasked with working on advanced or secret projects.

Could Google’s HelpOuts be a market place for expert patients?

This week, Google introduced a new product, HelpOuts. The idea is pretty simple: experts make their time available, at reasonable rates. Anyone can sign up for time with an expert. Google touts using HelpOuts for things like learning a language, doing yoga, getting help with computer programing and…wait for it… healthcare services.

On this week’s TWiG {This Week in Google} podcast, the hosts very quickly see the healthcare applications. In fact, they even postulate about using HelpOuts for assistance navigating [Healthcare.Gov](] and the insurance marketplace.

You are thinking what I’m thinking, right?

For starters, this throws the doors wide open for the idea of telehealth. For the price of a co-pay, you could dial up a doctor for a quick consult via Google Hangouts.

But, wait, there’s more!

What happens when patients are the experts? What if hospitals, doctors, and health systems could buy time with patients? Hey, we want to do this new service, would that be valuable for you? Or perhaps, could you help us review our new patient portal and offer suggestions for improvements?

I love these marketplaces which disintermediate the whole concept of expertise and time. We’re increasingly accepting of the idea of patients as experts. But, to date, there hasn’t been a great way to find the best patient experts by area of expertise and availability. Might HelpOuts prove to be the for pairing patient experts with provider organizations, other patients and the healthcare industry at large?

I bet, collectively, we can grow a list of some pretty clever healthcare uses for HelpOuts. For instance:

  • Employee health services
  • Dietary and wellness counseling
  • Billing and insurance form review – this one has huge potential, in my mind!
  • Rural healthcare delivery
  • Midwife and doula coaching
  • Second opinion
  • Medical librarian service for patients – someone who helps find articles and interpret them for patients

What thoughts come to your mind? Anyone thinking about signing up as an expert?

This Week in Google 223

StopThoughts: how to improve healthcare through reverse culture shock (or why CBPR matters)

note. introducing a new category on this blog: < /stop> thoughts. < /stop> thoughts are those ideas you hear that make you stop, cock your head, blink a few times and then feel goosebumps while your brain goes in a different than you had thought about before. In < /stop> thoughts, I’ll share concepts, often loosely defined, which I think have massive potential to disrupt, improve or otherwise positively effect healthcare.


Yesterday, I had a phone call with someone who I’ve gotten to know as a big thinker around socioeconomic determinants of health. That’s a mouthful of a phrase which I love. During our conversation, she introduced me to the concept of Community-Based Participatory Research, or CBPR.

From Wikipedia:

Community-based participatory research (CBPR) is a partnership approach to research that equitably involves, for example, community members, organizational representatives, and researchers in all aspects of the research process and in which all partners contribute expertise and share decision making and ownership.

From the National Institutes of Health:

Community-based participatory research (CBPR) is an applied collaborative approach that enables community residents to more actively participate in the full spectrum of research (from conception – design – conduct – analysis – interpretation – conclusions – communication of results) with a goal of influencing change in community health, systems, programs or policies.

And, from AHRQ:

In CBPR, community-based organizations (CBOs) or groups (such as churches, church members, neighborhood organizations, community residents, and other social organizations) help researchers to recruit subjects. But they do more than that. Community-based organizations play a direct role in the design and conduct of the research study by:

  • Bringing community members into the study as partners, not just subjects.
  • Using the knowledge of the community to understand health problems and to design activities to improve health care (interventions).
  • Connecting community members directly with how the research is done and what comes out of it.
  • Providing immediate benefits from the results of the research to the community that participated in the study.

Why isn’t very hospital service conceived of, planned and executed according to CBPR?

I know, some of you rival my cynicism (and mine pegs the meter). You’ll say but Nick, these organizations are more interested in the almighty dollar… And, perhaps they are. But, wouldn’t they stand to make even more dough by building and providing services which communities actually want and need?

Fundamental to the idea of CBPR is moving past assumptions. Designers call this co-design. I’m proud to serve on the board of the Society for Participatory Medicine —an organization which, among other things, promotes the mantra let patients help! So, this idea isn’t entirely new.

Here’s the < /stop> thought:

What’s exciting, indeed the < / stop > thought here, is how simple doing CBPR is, and how doing it would inherently cause a culture shift in healthcare.

Imagine hospital executives, planners and clinical leaders spending as little as 10% of their time visiting the communities they serve, and asking “what needs do you have, and how can we, as your local hospital, fill them?”


Take it as given that we’d see new, community and people-centered services. Maybe we’d see hospitals move to all organic, plant-based menus. Maybe we’d see them open medically supervised fitness centers. Maybe we’d see them move health services out of the hospital and into schools and churches. We might also see programs for mental health grow. Who knows‽

But we’d also see how the community would affect the hospital leadership and its culture. Do communities speak about health and wellbeing using the same terms hospitals use? Do most people in a community look, dress, act and present like hospital leaders?

Can you imagine the reverse culture shock?

And here’s the best part, I suspect, for those willing to embrace CBPR, it would feel good. Revenues will probably follow, but even better, I bet there’d be more joy for everyone involved and almost certainly better outcomes.

I’m reminded of how my friend Jason Albrecht closed his recent talk at Medicine X:

“Once you start this, you don’t want to stop. It feels good. It feels good because if feels right… it leads to a much greater sense of joy for everyone involved in the care process.”

—Jason Albrecht, MHA at Stanford’s 2013 Medicine X program

stop thoughts: we need Maker culture in healthcare

note. introducing a new category on this blog: < /stop> thoughts. < /stop> thoughts are those ideas you hear that make you stop, cock your head, blink a few times and then feel goosebumps while your brain goes in a different than you had thought about before. In < /stop> thoughts, I’ll share concepts, often loosely defined, which I think have massive potential to disrupt, improve or otherwise positively effect healthcare.

Last week, I had the opportunity to speak to over 300 cardiac surgeons, cardiologists, nurses and their administrative partners at the Bon Secours Heart and Vascular Institute’s annual conference.


Anna Young was one of the other speakers. Anna represents MIT’s Little Devices Lab and its MakerNurse initiative. MakerNurse draws its name and inspiration from the maker movement.

Maker is all about DIY culture —making things, hacking things, inventing things. The movement an online magazine, Make, and several annual Maker Faire events, billed as the greatest show and tell ever. I often think my 90-something grandmother should be in the Maker movement. Not a day goes by that she doesn’t hack something, like adding a big rubbery grip to a fork to make it easier to hold. That’s what being a maker is all about.


MakerNurse draws on the realities of nurses and nursing. Every day nurses hack their environment to improve patient care. For instance, in Anna’s slide deck, she showed a picture of a nurse who figured out that office supply clips were perfect for holding small oxygen cannula to the beanies that babies wear in the NICU. The clips keep the cannula in place. In another example, nurses in some developing countries are using empty plastic soda bottles as spacers for inhalers.

And, we don’t have to stop at nurses.

Recently I spoke with a pharmacist friend who is most certainly a maker. She heard about a nurse in her hospital’s PACU who was using wintergreen oil to help patients overcome nausea (clearly a MakerNurse!). My pharmacist friend was inspired to incorporate her complementary medicine training into the hospital’s pharmacy. So she purchased bulk aromatherapy oils and dabbed a little onto cotton balls. She put the cotton balls in plastic sandwich bags. Then, she took the bags around the hospital and stopped people —environmental services, nurses, maintenance, execs —and had them test the aromatherapy. Now she wants to give them scented cotton balls-in-baggies to patients to help combat side effects from medications, or as a simple relaxation aid.

Here’s the < /stop> thought:

What if every hospital adopted a maker culture and rewarded new ideas, inventions and devices with as much emphasis as we reward a traditional career progression? What if hospitals provided employees, even patients and families, with tools and spaces to help them make new things and quickly test them out?

In healthcare, we often think vertically about careers and progressions. In the clinical environment we call it practicing at the top of the license. For instance, nurses should give injections rather than doctors, so doctors can use their time to do the things only doctors can do. When everyone is practicing at the top of their license —doing the things they are uniquely qualified to do —the system is, in theory, more efficient.

But, MakerNurse demonstrates is we can have a different type of value in our roles. For nurses, practicing at the top of their license means doing more direct patient care, clinical navigation, etc. Being a maker, by hacking processes and systems and building new things out of nicknacks, provides another avenue for nurses to contribute to improving healthcare; and that path is perhaps less limited by regulations and licenses.

If we, as an industry, valued that kind of DIY attitude, think about how many great ideas would be born, tested and put into practice? Might it also contribute to a different sort of career path or sense of professional fulfillment? What if patients were also encouraged and given tools to hack new things to improve their own care?

So, which hospital is going to be the first MakerHospital?