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Letter from the Chair: Taking a Triple Aim on Emergency Medicine

Jeffrey Pothof MD, FACEP

Jeff PothofThe year was 2008 when Dr. Donald Berwick and colleagues first published the Triple Aim for healthcare.1 Since that time healthcare has had varying degrees of success on achieving those aims. We don’t often talk about the Triple Aim as emergency physicians. It’s not something that comes up frequently in discussions on shift. Emergency physicians, however, are reminded daily the impact of not achieving the aim, the cracks it leaves in our healthcare system and the toll it takes on our patients.

The Triple Aim is broken down into better care, better health, and better value. Better care comes from the six dimensions of health care performance as outlined in the 2001 Institute of Medicine’s “Crossing the Quality Chasm.2 This includes safe, effective, patient centered, timely, efficient, and equitable care. We as emergency physicians all too often see care that is anything but timely; we are faced with balancing effective care with patient centered care. We see inefficiencies in repeating lab tests and imaging studies because our health records don’t reliably communicate across systems. Every day we are reminded of the disparities in our healthcare system standing shoulder to shoulder as the safety net for our communities.

Better health is expanding our definition of health and thinking more broadly about the population that depends on us. It’s estimated that clinical care accounts for only 20% of a person’s overall health. We should ask ourselves what role we play in promoting healthy behaviors, in addressing social and economic factors, and the physical environment patients come from. As emergency physicians we are tasked with more than just managing the heart attack or the trauma patient. I would argue the more challenging component of our work is addressing substance abuse and trying to figure out a safe disposition for that patient that you know won’t be able to make a follow up appointment. It is realizing that having to worry about where your next meal is coming from makes it hard to worry about your blood pressure. It is knowing your patient is a good person, but struggles with difficult circumstances.

Better value is reducing the elements of care that won’t improve health. It means taking the time to explain why a head CT isn’t needed instead of just writing the order and moving on. It’s working on individual care plans for those that have high utilization so they can get the right care, at the right time, and at the right location instead of just accepting that they are going to come to your emergency department day after day.

Emergency physicians are immersed in the Triple Aim all the time. We see firsthand the issues that the Triple Aim refers to. Sure, there are times that we’re treated unfairly and things just don’t seem to be in our control, but most of the emergency physicians I know didn’t get into this specialty for glory or self-admiration. We didn’t sign up because we thought it was going to be easy or convenient. We came on board because we wanted to make a difference 24/7/365, without the need for frequent or external validation to know it. Emergency physicians have grit. We persevere. The question that remains is what might happen if emergency physicians collectively took aim at the Triple Aim with the same gritty perseverance we bring to the emergency department? I frankly can’t think of a better group of providers to give it a shot.

  1. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood). 2008;27(3):759-69.
  2. Institute of Medicine (IOM). 2001. Crossing the Quality Chasm. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C: National Academy Press.



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