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The Future of Emergency Medicine Part I

David Meyers, MD, FACEP

On December 4, 2013, the respected journal Health Affairs sponsored a conference on “The Future of Emergency Medicine”, the theme of the December 2013 issue of the publication. Founded by John K. Iglehart in 1981, Health Affairs is an influential thought leader among America’s health policy resources.  Speakers at the conference, many well-known to us in QIPS and ACEP, were all contributors to that issue of Health Affairs and addressed different aspects of our emergency health care system.  What follows is my sense of the highlights of the conference.  Full audio and video links to the program are available online

The first speaker, Nicole Lurie, HHS Assistant Secretary for Preparedness and Response, presented an overview of mass casualty responses in the US, citing experiences and observations around Hurricane Katrina and the Boston Marathon bombing and specifically the crush of patients in EDs leading to great stresses on the people and systems there who performed admirably in spite of adversity.  Her office is working on answering basic questions about how a system of care delivery should work, especially in times of disasters and mass casualties.  The goal is to use that as the basis for creating better systems and coalitions for coordinating and delivering such care.

Art Kellerman, MD, FACEP was introduced and presented an excellent brief history of emergency care and our specialty. He described the pre-EMS era and how EMS services evolved from primitive load-and-go hearses which served as de facto ambulances to the changes which rapidly ensued after the 1966 National Academy of Sciences report “Accidental Death and Disability: the Neglected Disease of Modern Society”. He cited key markers for the evolution of EM: the Alexandria plan of 24-hour coverage by dedicated physicians in the ED instituted by James Mills and colleagues in 1961; John Wiegenstein and the 7 emergency physicians who founded ACEP in 1968 and pushed for specialty recognition; the University of Cincinnatti’s first EM residency in 1970; USC’s first academic EM department in 1971, JACEP in 1972, and other milestones leading to a comprehensive approach to emergency care now largely taken for granted.  He also described the enactment of EMTALA, which established a right to health care for all in the ED for emergency conditions.  Finally, he noted the tremendous pressures now causing crises of ED capacity, crowding and boarding.

As for as his view of future trends, he proposed these as driving forces in EM:

  1. Integration of ED care with other care resources;
  2. The regionalization of specialized acute care, modeled after the trauma systems;
  3. A greater focus on prevention;
  4. Innovation to enhance quality and value in the ED and across the continuum of care.

These predictions were generally agreed on by many other speakers in the program.

Ricardo Martinez, MD, FACEP, now the CMO of North Highland Worldwide, and Brendan Carr, MD FACEP, the director of the Emergency Care Coordination Center (ECCC) in the Department of Health and Human Services (HHS), described the dysfunction of our poorly coordinated local and Balkanized models of care delivery and argued for integrated systems of care. This includes the management of populations to optimize quality, operational efficiency, and costs.

Jeremiah “Jay” Schuur, MD, MHS, FACEP noted that there are few measures of the full scope of ED care at present. Current focus is on timeliness of care markers (door-to-balloon in AMI, door-to-antibiotic for pneumonia, door-to-discharge, -observation, or -inpatient admission) and patient satisfaction. In his view of the future, the 6 priorities of National Strategy for Quality Improvement in Health Care (National Quality Strategy - NQS), a component of the Affordable Care Act, figure prominently, even though some have not heretofore been emphasized in the ED http://www.ahrq.gov/workingforquality/about.htm

  1. Making care safer by reducing harm caused in the delivery of care;
  2. Ensuring that each person and family is engaged as partners in their care;
  3. Promoting effective communication and coordination of care;
  4. Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease;
  5. Working with communities to promote wide use of best practices to enable healthy living;
  6. Making quality care more affordable for individuals, families, employers, and governments by developing and spreading new health care delivery model;

As a practical matter, these will come in the form of ED efforts to prevent leading causes of mortality, including: falls in the elderly, vaccines to prevent common childhood diseases, promoting seat belt use, alcohol treatment referrals, reduction of diagnostic errors and healthcare-associated conditions, greater care coordination, and better communication between provider and patients. To affect these goals, the following will be needed:

  1. Broader quality measure sets;
  2. Evidence-based best practice strategies to guide diagnostic testing and treatments;
  3. Improved data including outcome registries and from EHRs
  4. Greater public reporting and value-based reimbursement models.

A panel of speakers addressed EM workforce issues noting the expected increasing role of mid-level providers, telemedicine and mHealth in catering to increased demand.  Also discussed were various funding models for emergency care and some vexing problems such as the future of disproportionate share hospitals, cost-shifting and the impact of the Affordable Care Act.

A break ensued after these presentations at the conference, and we’ll also save the rest of this update for the next newsletter.  Stay tuned…

 

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