For many physicians, developing an ongoing relationship with patients is a rewarding part of the job. That’s not the case for emergency physicians like me — we’d rather not see the same patients over and over again, especially those with substance use disorders, who are some of the highest users of emergency care.
I can vividly recall the first time that the opioid epidemic became real to me. One day in September 2011, I was working in the emergency department when a 23-year-old patient arrived in cardiac arrest, apparently caused by an opioid overdose. My team did what it could, but we could not resuscitate the patient. When I talked with his family, they told me that multiple care providers had written him prescriptions for pain medications.
That got me wondering if this tragedy could have been prevented if his providers had been able to easily and securely coordinate his care. Could having that kind of information have prevented the ridiculous number of prescriptions written for this patient?
The ever-growing problem of opioid addiction has come to the forefront in my profession and in communities across our nation. It is now getting state- and federal-level attention. Unfortunately, given the complexity of the health care landscape, providers can’t wait for a mandate to plan and implement a solution. We need to take the bull by the horns and do it ourselves.
That’s what colleagues and I learned when we tried to address the excessive use of emergency department care in Washington State in 2011. The recession of 2008 had triggered an uptick in job losses that correlated with an increase in Medicaid beneficiaries, many of whom lacked access to primary care and turned to the emergency department for help — with little or no budget for innovation.
A group of organizations including the Washington state chapter of the American College of Emergency Physicians, the Washington State Medical Association, and the Washington State Hospital Association — as well as the state’s hospitals — were given the responsibility of finding their own way to lower emergency care for the highest users of emergency room care, 48 percent of whom had substance abuse problems.
We launched the ER is for Emergencies program in the summer of 2012. Within just 12 months it had reduced emergency department visits by nearly 11 percent.
Based on my experience as part of this groundbreaking program, I can attest that a change of this magnitude wouldn’t have been possible without two things: a system that allowed us to share information with all other hospitals in the state and a shared commitment to teamwork and a common goal.
Putting opioid use and readmissions into focus
The biggest motivator for launching the ER is for Emergencies program was a lack of state Medicaid funding to address the high use of emergency care. We realized that waiting for some kind of massive, sweeping, well-funded state-wide initiative would take forever, and we didn’t have forever. The only way to quickly drive meaningful, long-term change was to treat our state’s opioid problem as a collective burden, not a competitive quality metric. As such, nearly every health system in the state came together for the initial launch of the ER is for Emergencies program, despite a lack of state funding.
The first step we took was to adopt a secure technology platform. The one we used is called Emergency Department Information Exchange (EDIE), developed by a company called Collective Medical. The system was already in use in about 35 percent of hospitals in Washington at the time, and the state mandated its use as a part of the ER is for Emergencies program. EDIE isn’t the only platform that could potentially facilitate this kind of program — other systems, such as those developed by electronic health record vendors such as Epic and Cerner, could also have been used. We chose EDIE because we needed a tool that was not tied to a specific electronic health record, one that could extract precise information — the most relevant data pertaining to patient ER visits — from a diversity of sources the moment we needed it.
EDIE works by combing through admissions, discharge, and transfer data, along with other sources, to identify patients with high emergency department use as soon as they are admitted. For our program, these were patients with more than five emergency department visits or transports in the prior year. The system also provides a one-page report containing the most essential patient information for physicians at the point of care, such as prescription management recommendations.
In addition to recognizing frequent users of the emergency department and emergency medical systems and developing care plans — which include opioid guidelines for patients with a high risk of potential opioid abuse — the system helped us better direct case managers to offer immediate referrals for patients whose care could be managed by a primary care physician and improve care coordination for complex visits such as patients with schizophrenia, heart failure, or sickle cell disease.
The end result, as reported by the Brookings Institution, was a nearly 11 percent drop in the rate of visits by frequent users, and a 24 percent reduction in the rate of visits resulting in a prescription for controlled substances. In its first full year of operation, the ER is for Emergencies program saved $34 million in emergency costs.
Hospitals in other states, including Alabama, where now I live and practice emergency medicine, are pushing to follow Washington state’s lead.
Providers in other states don’t need to wait for a mandate — or for federal or state funding — to guide them. They can be proactive leaders, guiding their peers and patients toward a solution. Keeping the Emergency Medical Treatment and Active Labor Act of 1986 in mind, health care providers are bound by a responsibility to get all patients the care they need, but also to identify patients with high emergency care use. Based on my experience in Washington, and now in Alabama where this movement is in its infancy, I have three recommendations for reducing inappropriate emergency care:
Engage physicians and health care leaders. Winning buy-in from physicians and health care providers is key to any program’s success since those individuals and teams are the ones who use essential data at the point of care to make decisions. For a collaborative program to succeed, emergency physicians and the broader care team must be included in initial planning stages. This ensures that everyone understands how new technology will be incorporated into existing workflows. It also helps the participants better understand how technology can help them share information and do things collaboratively they’ve never done before.
Start small. The initial goals of ER is for Emergencies were simple and resource conscious: lower the utilization rate of less urgent conditions in the emergency department and redirect patients to the appropriate care path. Having just a couple of goals gave those involved a clearer focus. Once a state-wide program has demonstrated success, it can be extended to other areas of medical care. In Washington state, for example, hospitals are now working with payers on new patient populations, such as patients with chronic disease states like heart failure, that have high costs or high use of emergency care.
Emphasize value. Stakeholders need to see the numbers: How will a particular program or technology system help reduce utilization? How would reduced utilization improve outcomes? How much money could a program ultimately save an organization? When health care leaders understand the real value of a program such as ER is for Emergencies, they become more excited about participation. And while upfront costs may feel challenging to some administrators, the upstream savings are potentially exponential compared to the downstream costs.
There’s no question that providing better care at a lower cost and reaping all of the benefits of a program like ER is for Emergencies requires some up-front investment. But while funding can be an essential part of a successful health care initiative, it isn’t the only factor influencing success. As with any grassroots effort, success is measured by how many of those involved see themselves as part of a bigger and more profoundly effective movement. Having the right team in place is essential to creating a solvent and more cost-effective solution that can deliver real value and impact.
While no solution can guarantee high-needs patients won’t fall through the cracks, programs like ER is for Emergencies can help us catch many more of them before they’re triaged in the wrong direction.
Hamad Husainy, D.O., is an emergency physician at Helen Keller Hospital in Sheffield, Ala., a board member of the Alabama Chapter of the American College of Emergency Physicians, and founder and CEO of Sycamore, a health technology startup addressing the rising costs of staffing in health care.