The 5-Tools of Physician Leadership in the 21st Century

moneyball posterVery rare to come upon a young man like Billy. Who can run, who can field, who can throw, who can hit and who can hit with power. Those five tools you don’t see that very often….we’re looking at a guy who is a potential superstar.” (Moneyball, 2011)

 

In the movie MoneyBall they refer to the lead character (played by Brad Pitt) as being a five tool player when he was being recruited out of high school. Being a 5-tool player mean being able to (for both average (1) and power(2) ), throw with speed and accuracy (3), field (4), and is fast with great base running skills (5). It is acknowledged that most players only have 2 or 3 of these and that a true “five tool baseball player” is rare.

All physicians are leaders. We lead clinically every day. We provide leadership as we care for patients, supervise residents and medical students, and interact with all the other allied health providers. the concept of the 5-Tools of Physician Leadership is geared to those that provide leadership to other physicians.

I believe that there are also five vital tools that Physician Leaders in the 21st Century need to have. They address the fundamental thing we need….the ability to lead change in chaotic times.  The more they hone these skills the more successful they will be. Like in baseball very few will be perfect in all five .

The tools that physician leaders need to  have are:

  • Solid and respected clinical skills (1)
  • Comprehensive communication skills (2)
  • The abilities to Create (3), Execute (4) and Sustain (5)

While the first two are hardly “new”, the emphasis on creating, initiating and sustaining change are a 21st century phenomenon.

Clinical Skills:

tt-positions-greenNo matter how much the practice of medicine changes or will change it is ultimately a conservative and somewhat insular discipline. While we practice many specialties there are commonalities: The experience of medical school and residency and the focus on patient care. Without a solid clinical base recognized either from years of clinical practice or possession of coveted knowledge it is unlikely other physicians will follow you. Furthermore the perception that you are no longer sufficiently clinical (ie swinging a hammer) can also reduce your value on clinical matters. Simply put physician leaders must stay grounded somehow in the clinical world no matter how difficult that could be time-wise.

Communication:

email picThis is perhaps the most difficult of the 5-Tools to define. It takes some courage to get up in front of your distinguished peers and tell them to do something.
It is even harder to get them to listen. We are used to communicating with each other clinically. But this is different. You have to find both universal messages that work for all physicians but also appeal to the differences within and between specialties.

Communication also requires mastering different media. In an average sized hospital it would almost be impossible to communicate only in person. Most physicians (40ish and above) can be reached reliably through emails. Very few physicians under 30 these days ever open email and prefer texting and other mobile app based venues.

Create, Execute and Sustain:

technologyMedicine is becoming more integrated, more coordinated and requires cooperation across not only specialties but also disciplines (nursing, allied health, etc). If physicians are to lead they must be able to influence the way care is provided. Physicians should be well suited for these tasks. From 3rd year of medical school on we have been creating differential diagnosis, initiating treatment plans and sustaining the attention required to complete our rigorous training.

These three tools though are separate and unique. We have all met physicians who have great complex ideas that they expound upon at every staff meeting. They have vision and passion (to create) but are unable to translate that into action or sustained results.

On the opposite end is the physician who is frequently belittled by colleagues but loved by chairs. She or he is always the first one to turn in their required paperwork, is never late with their charts, and carries forward the protocols and policies of their department (the Sustainer).

The Executor is like the shock troop of change management. Able to rally their medical staff or department and charge full force into the unknown. They are able to translate the creative ideas into action and start the ball rolling. They understand the pros and cons of the change and provide the energy to get the initial job done. Like the Creators however they frequently lose interest after a while and sustained change is threatened.

Summary:

As stated earlier it is rare to find a truly 5-Tool Physician Leader. Some of the most successful I have known only possessed 2 or 3 but were smart enough to surround themselves with others who possessed the other tools. It is important to remember that while these tools are vital to a physician leader they are not the only skills needed. Comfort with data and analytics (both Big and Little Data) along with a fundamental understanding of finances and budgeting are crucial as well.


The Anatomy of a Super ER – Part Two

ER outside

Part One of Anatomy of a Super ER started with the morning ritual of change of shift and set the scene by highlighting what Paterson ER has to offer in terms of space, staff and technology.

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Part Two will follow the action of the day highlighting the processes in place to treat a large number of patients efficiently while also ensuring that those with specialized needs get cutting edge care.

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ED blueprint

ED Treatment Areas

By 11 am all 100 treatment areas are open. Until well past midnight all these beds will be in nearly constant use. In a perfect world some beds would always be open for incoming patients. But the world is rarely perfect.

 

Beds typically will remain empty for only as long as it takes for the first patient to leave and the next patient to be moved into it. At times demand will exceed this capacity anywhere from 10-40% (11-14 patients for every 10 beds). Configuring operations to be lean and efficient are key to handling the constant demand.

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CAPACITY / DEMAND

ed-signPatients arrive to the ED by different methods but enter only one of two ways : through the waiting room or the ambulance entrance. The majority (85%)  will “walk in” and present to the triage desk in the waiting room. However, critical patients will be included in this flow of humanity. Nearly 1/4 of all heart attack and stroke patients along with a smattering of patients with gunshot wounds will “walk in”.

 

TRIAGE was created as a way to “sort” patients and then expanded to capture relevant and mandatory data. This expansion beyond the purpose of sorting has made “traditional” triage time consuming (5-10 minutes per patient) and a major bottleneck. Patients can end up waiting to complete triage even when a treatment bed is open.

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In order to meet the demands of the up to 30 patients an hour who are arriving, Paterson ER has been re-engineered to streamline care. Paterson ER has a PIVOT or abbreviated triage  that is conducted within 10 minutes of arrival.

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This brief evaluation (age, chief complaint, heart rate and pulse oximetry) gets back to the basics of sorting the patients by acuity but also goes a step further and assigns patients to specific queues. Even though it takes about a minute to complete the accuracy of acuity and location assignments are very high.

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A second part is ensuring that the patients’ needs match the workflow of the area they are sent to. This means trying to keep the patients who can remain ambulatory and upright out of beds that have average lengths of stays in the hours.

supertrack flowMost ambulatory patients are treated in our Supertrack. The physicians and nurses in this area are focused on patients who can walk and generally only need 1-2 tests/treatments. A good example would be patients with complaints of localized injuries (cuts, joint pain, wrist fractures) or limited medical complaints (moderate asthma, viral symptoms, etc). At Paterson ER this enables a 9 bed treatment area to have 15-18 patients in process. The creation of virtual beds reduces time to be seen by physicians and total length of stay. The average patient in Supertrack is in and out in under 100 minutes.

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SUPERTRACK – Similar to the concept of the Fast track where patients with noncritical complaints are sent for care with the idea of keeping them out of the Main ED and speeding their care. In the Supertrack patient are seen in private treatment areas but then moved to internal waiting areas while awaiting tests to be completed. Currently over 100 patients a day are treated and discharged from these areas.

 

mc-1119l-l1doctorrstOf course some patients need the opposite of this. They need more monitoring and time. One of these groups are elderly patients. The 20 bed SrED (Senior or Geriatric ED) cares for the majority of patients over 65 years old. While the needs of this group are tremendously variable there are some commonalities. They need more extensive examinations and history taking including a review of all medications.The probability of serious illness or injury is also much greater.

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Seniors tend to benefit from a quieter and better lighted area as well as thicker mattresses to prevent pressure injuries. The SrED staff has received special training on the care of these high-risk patients. With the help of this dedicated area the average door to doctor time for Seniors is between 15-20 minutes.

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Lives Saved While You Wait

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The majority of patients seen on this day will go home (nearly 90%). However some will arrive in critical condition and need immediate life saving interventions. For them any amount of delay can be deadly (SEE Code Black). These are the patients that emergency nurses and physicians live for. Their care is based on the single minded belief that you put yourself next to the critically ill/injured patient and treat them aggressively. The resuscitation of a critical patient is a full contact sport.

04a_t607Rarely is that team composed only of emergency department personnel. Frequently what the patient needs must be drawn from the expertise of the entire hospital (SEE trauma team). This care must be coordinated and time compressed. The immediate goals are stabilization of the ABCs (airway, breathing and Circulation) with preparation for definitive care. [That definitive care includes cardiac catheterization for patients suffering heart attacks and emergent surgery for select traumatic injuries]. As many interventions as possible are performed simultaneously. For those involved time stands still and attention narrows only to this one patient.

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tt-positions-greenTRAUMA TEAM – Several times a day a page goes out “TRAUMA ALERT ADULT ED”. This summons a large group from within the ED and across the hospital. The team is led by a board certified trauma surgeon and includes an emergency physician and resident (critical for airway management), surgical residents, ED nurses and med techs, respiratory therapists, and radiology techs (xray and CT). The activation of the trauma team also puts a CT machine on hold, blood products on standby for emergency transfusions, and alerts the OR staff of the possibility of an emergent case (one OR is always on standby).

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The transition from day to night will see the same cycle. Patients come and go. Handoffs between staff attempting to make care seamless. Towards midnight the pace of incoming patients begins to slow and areas that opened at 8 am or 11 am  are now closing down. By four am only a few patients will appear as the night team finishes up the care of their patients. 7 am is just around the corner when the day will start all over again….

7 clock

 

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Written by:

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David Adinaro MD, M.Eng., FACEP

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professional david adinaroDr. Adinaro is the Chief Medical Information Officer and Patient Safety Officer for St. Joseph’s Healthcare System in Paterson, NJ. He remains active as an emergency physician in the Paterson ER. Dr. Adinaro can be reached via  @PatersonER .

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This publication represents the personal opinion of the author and does not reflect his employer.


Prescribing Narcotics in the ED: A Rational Approach in a Changing World

“Cure Sometimes. Treat Often. Comfort Always”  - Hippocrates (400-ish BC)

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What is doctor to do?  We have a mandate to treat pain and relieve suffering, but some of the best medications available have high abuse potential and are involved in an epidemic of unintended morbidity and mortality.

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Do we as physicians prescribe too many narcotics?  Specifically do we emergency physicians prescribe more than we should? As with much else in medicine the evidence is complex and at times contradictory.  Some examples of the argument that we are not aggressive enough in the treatment of pain are the following (click on them to access links):

If you have spent any time looking at the news or proposed state legislation the answer would clearly be yes. There is an epidemic of deaths related to prescription drug use and misuse. The problem is stark both in terms of the individual tragedies and sheer numbers.

 

drug deaths

 

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My goal in this piece is to lay out the problem from an emergency medicine perspective and to suggest a set of guidelines that might help my colleagues in their daily struggle to figure out what the right thing to do is for each patient. This is based on a lecture I delivered at NJ-ACEP Scientific Assembly in May 2014 (Click here for slides: The Pendulum Swings).

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To start out let me disclose the following to understand my perspective:

one year of prescribing
I am a prescriber of narcotics….

  • One year thru March 2014
  • Cared for 2,700 patients
  • 318 filled prescriptions for CDS (down from 390 year prior)
  • Averaged 18 pills per script (19 in year prior)

 

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Who rarely prescribes “Higher Potency/Longer Acting” formulations:high potency

 

  • 30mg Oxycodone (2 scripts)
  • Morphine 15mg (1 script)
  • Dilaudid 2mg (2 script)
  • Oxycontin 20mg (1 script)

 

 

 

 

AND a patient who has received narcotic pain medication…

accident 2
  • Winter of 1988-1989
  • MVC (while as EMT in ambulance)
  • Femur Fracture
  • Surgery x 4
  • Meperidine, Morphine, Oxycodone
Capture

 

 

  • Summer 2014
  • “El Diablo” (kidney stone)
  • 4mm UVJ
  • Toradol and Oxycodone

 

 

 

The Modern Culture of Treating Pain

pain scaleThe introduction of  pain as  “The 5th Vital Sign  in the mid-1990s coincided with an explosion of prescribing of high potency and/or long-acting narcotics. The need to measure pain was codified by the Joint Commission at the start of the 2000′s.

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From an ED point of view pain scales may or may not be useful as the median pain score is an 8.

 

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Heavy advertising especially by physicians to physicians for drugs such as Oxycontin® culminated in this being a block-busting $1Billion drug by 2001.

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Eventually the FDA found the manufacturer had engaged in misleading and dangerous advertising. But by that time an epidemic had begun.

 

 Is this an ED Problem?

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Not surprisingly the answer turns out to be yes and no….

  • We make up 2-5% of all narcotics prescribed and filled.
  • We generally prescribe only 15-20 doses of the lowest strengths
  • However….A significant number of our  patients are “at-risk”
  • AND…. Most EPs feel at least once a shift they are being manipulated for drugs

 

at risk

While it is easy to label certain patients as drug-seekers the reality is much more complex. It is probably more useful to approach this from a RISK perspective.  Data suggests that approximately 10% of those receiving narcotics are “at-risk”.

at risk logan
  • Diversion
    • False names, false addresses, no actual medical complaint
  • Multiple Visits for Acute Conditions
    • Toothaches, traumatic injuries, visceral organ pain
  • Chronic Pain from non-specific conditions
    • Migraines, Low Back Pain, Fibromyalgia, Chronic Lyme disease, etc.
    • C1-Esterase Deficiency
  • Chronic Pain secondary to specific medical condition
    • Gamut from SCD, Gastroparesis, Chronic pain after surgery
    • Headaches secondary to history of Brain Aneurysm, Recurrent Renal Colic
  • Pseudo-Addicted 
    • A drug seeking behavior that simulates true addiction, which occurs in patients with pain who are receiving inadequate pain medication
  • Addicted (hard to distinguish from pseudoaddiction)

 

A Rational Approach to Narcotic Prescribing

in the Emergency Department

 

the ed challenge big

The holy grail in emergency medicine has shifted from figuring out which patient with chest pain can be discharged safely to which patient can I safely give narcotics. This, of course, must occur in one of the most complex and information-challenged environments in healthcare. Physicians must balance all this with these other priorities. Here are some guidelines that could be helpful:

 

 When prescribing narcotics:

  • Screen for substance abuse as needed
  • Emphasize risks to patient
  • Encourage safe disposal of left over medication
  • Continue to use short-acting formulations
  • Generally limit amounts to five days
  • Strongly consider alternatives in patients already taking benzodiazepines
  • When practical avoid parenteral medications for exacerbations of chronic pain
  • Have a higher threshold for certain conditions including dental pain, sprain

Use your State’s PMP consistently to screen for “at-risk” behavior when:

  • Multiple “recent” ED visits
  • Exacerbation of chronic pain
  • Patient requests medications by name
  • Allergies to multiple alternative medicines 
  • Not from typical catchment area
  • Before prescribing LA opioids for non-cancerous pain
  • For more on Prescription Monitoring Programs  (PMP) see this blog:
too much too little

When clinical judgement and/or data suggests “at-risk” behavior:

  • Share concerns with patient
  • and negotiate no CDS prescription vs. smallest amount possible
  • If possible speak with primary medical doctor for coordination

If pseudo addiction suspected coordinate closely with PMD:

  • Arrange appropriate follow up
  • Use best judgment in terms of prescribing CDS

Establish intra-departmental protocols for the most common conditions

    • Oral protocols for chronic pain exacerbations
    • Common approach to repeat visits for CDS prescriptions
    • Add tools to your tool box
      • Alternative therapies
      • Dental blocks

As always this is one emergency physicians opinion based on a fair amount of research and discussion. I would love to hear your opinions and questions. 

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professional david adinaroDr. Adinaro is the out-going president of NJ-ACEP and is the Chief of Emergency Medicine at St. Joseph’s Regional Medical Center in Paterson, NJ. David can be reached via  @PatersonER . This publication represents the personal opinion of the author and does not reflect the policies of his employers.

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The Anatomy of a Super ER – Part One

ER outsideMuch like British naval vessels once considered noon the start of their day,  7 am is the start of the day in the Paterson ER (150,000 visits per year). During the next 24 hours an average of 415 patients will seek care (Monday and Tuesday always being the busiest). They will be cared for by 17 emergency physicians, 4 nurse practicioners, and 45 nurses supported by three dozen scribes, techs, transporters and registration personnel.

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7 clockBut for now only about 30 patients are in the department. It is a busy time of transition. The night shift physicians and most of the nurses have been here since 7pm.  When they came in nine zones were humming along at full power. Now they are turning over only four areas to the day shift.

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Before the new team can begin caring for patients the off-going  Team must sign out. Physician to physician. Clinical nurse to clinical nurse. Charge nurse  (See Inset) to charge nurse. All patients in the emergency department proper are “owned” by someone. This ownership (responsibility) forms the basis of the complex systems that provide medical care.

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Private-ED-Rooms-SJRMC“Ownership” in the Paterson ER is geographical. This very large ER (88 beds with 15-20 additional spaces for overflow) is broken down into nine zones (excluding the Resuscitation bays and Psych area). Each zone is staffed by a set team of one physician and two nurses for 8-10 beds. They are supplemented with a scribe for the doctor, trainees (residents, medical students) and pull from a pool of transporters, registrars and techs.

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CHARGE NURSE – The senior nurse responsible for the immediate operations of the department. Typically all personnel (excluding physicians) work directly for the charge nurse during their shift. The charge nurse generally has the most comprehensive situational awareness from moment to moment and handles  100+ communications per hour. They are traffic controllers, problem solvers, coaches, fixers…. all-knowing and all-important.

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Because of this scale areas have specialties. Zones 1-3 (Main ER) care for adults, are open 24 hours a day and receive the most critical patients. Zones 8 and 9 are pediatric and also never close. Zone 4 (also known as Supertrack) is a hybrid unit taking care of ambulatory patients with low to moderate intensity complaints. Zones 5 and 6 make up the SrED (Senior ED) and specializes in the care of those 65 and older. Finally Zone 7 is an area in transition currently taking care of the excess demand the other units can’t handle.

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ED blueprintAt 7 am with only four zones open (3 in Main ER and one in Peds along with the Psych and Trauma areas), the department can comfortably handle the roughly 8 patients an hour that are arriving. Beginning at 9 am that rate will sharply increase until 20 patients are presenting for care per hour. As demand increases more zones with more beds will come on-line.

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EMERGENCY PHYSICIAN – A physician who practices exclusively in emergency departments after receiving specialized training during their residency (after medical school). Generally certified by the American Board of Emergency Medicine or American Osteopathic Board of Emergency Medicine. PatersonER has one such training program that graduates six physicians per year. While residents they are closely supervised by emergency physicians as they learn the art and science of the emergent evaluation of the acutely ill patient.

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The pattern will be much the same for each of those 415 patients. 1)Come in, 2) get triaged (sorted), 3) go into a treatment area (bed), 4) be seen by the doctor and nurse, 5) receive ordered tests and treatments, 6) receive a disposition and 7) leave. Some patients will require this faster, others slower.

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Some will require very intensive care and others just an xray or a prescription. Frequently those who are dying will be saved. Sometimes though a patient will die. All will be touched by multiple people and their care will require the close cooperation of multiple departments and systems during their stay. Compassion amongst organized chaos will be the order of the day

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trackingTechnology plays a big role in modern healthcare but particularly in a SuperER. Without electronic medical record system (EMR) that integrates bed management, medication/test ordering, charting, and disposition planning there is no way this complex system could function. Though paper certainly exists in the ER more and more information is transmitted electronically. It is not unusual for physicians to have 4-5 different program running in order to access their patients’ current information, previous history, lab results, and digital images of radiology tests (CTs, ultraounds, etc).

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ultrasoundBEDSIDE ULTRASONOGRAPHY – Since the 1980s emergency physicians have been making use of bedside ultrasound machines to expedite the care of patients and improve care. Commonly they are used for the evaluation of abdominal pain, complications of pregnancy, and rapid diagnosis of the critically ill (FAST exam – see image). This great, non-invasive technology is also being used to make certain high risk procedures safer including the placement of central venous catheters.

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Next week Anatomy of a SuperER – Part Two will highlight some of the important innovations at PatersonER including Pivot Triage, the SuperTrack, and our astounding evolution of the emergency care of geriatric patients. We will also get in depth into the care of some of the most critical patients including those with major trauma and life threatening heart and brain emergencies. Stay tuned!

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Written by:

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David Adinaro MD, FACEP

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professional david adinaroDr. Adinaro is the president of NJ-ACEP for 2013-14 and is the Chief of the Adult Emergency Medicine at St. Joseph’s Regional Medical Center in Paterson, NJ. He is also the current editor of the “Year of Confusion…Year of Opportunity: 20 Things Changing Emergency Medicine” blog. Dr. Adinaro can be reached via  @PatersonER .

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This publication represents the personal opinion of the author and does not reflect NJ-ACEP or his employer.


ER 2030: The Future of Emergency Medicine?

SJRMC CRITICAL CARE BUILDING “If only I had a crystal ball…”

I don’t. So I had our residents participate in an exercise where they brainstormed on what the ED of the future will require. I thought as they are part of the future of medicine they would have some great ideas. How right I was!

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I gave them as background the following:

  • That currently EDs account for about 4% of HealthCare costs
  • Control upwards of 15-25% of expenditures (admissions)
  • Patients managed at home will become increasingly complex
  • Expectations are that more acute/chronic treatment will be outside of in-patient hospital units

I then gave them a specific patient in the year 2030:

  • 64 year-old recently retired physician (me in 17 years)
  • Complaining of fever, chills and abdominal pain with a history of diabetes and hypertension
  • Most medical records not at this institution

I then asked then to describe the necessary changes, improvements, technologies, that would be needed to care efficiently for 250,000 patients a year (our current volume 150,000)  and provide proper, coordinated care for the above patient. I asked them to consider the following:

  • Emphasis on coordinated care
  • Integration of technologies
  • Information management
  • Patient flow

technologyTECHNOLOGY

Being a group firmly planted in Generation Y they were very comfortable and specific on the need in terms of technology. They wanted healthcare technology to be as universal, easy to operate and intuitively obvious as what the make use of on a daily basis now.

A number of their suggestions were focused on electronic medical records and the need for them to be more portable, multimedia, and interactive.  Aside from the obvious need for a universal medical record they also suggested:

  • Incorporation of photos especially of wounds for comparison
  • Fingerprint ID
  • Personalized electronic discharge instructions (to phone/email, etc)
  • Personalized charting software
  • Improved dictation systems
  • System integration (one screen for all records – ED, past hospitalizations, Radiology, Lab, PMPs)

Their other technology improvements were focused on very specific patients issues:

  • I-Cloud Microblood Chip (implanted blood analyzer)
  • Affordable Pad-based ultrasounds
  • Advanced, non-radioactive cardiac imaging
  • Video-Chat for prehospital calls and communicating with other physicians
  • At-home telemetry
  • Universal health care provider communications (eliminate answering services)
  • Virtual Translation services
  • Wireless EKG
  • Jetpacks for patient transport (my favorite!)

health care system

SYSTEMS

To be clear systems are not all about computers but rather the structures humans create to accomplish specific tasks. Health Care systems are by nature complex, dynamic and tightly coupled (See posts on High Reliability ED). For many physicians in training this is not a well understood concept. Residents, to be honest, spend most of their time mastering the medical parts of health care and do not generally look at the systems they work in. However, our residents did a great job suggesting needed additions to our current systems to improve the efficiency and coordination of care.

  • Expanded use of observation units
  • Telephone triage (prior to arrival)
  • On-site access to primary care (directly from triage)
  • In-house pharmacies in EDs
  • Shuttle systems for getting patients from ED directly to primary care sites
  • Kiosks for patient entered medical data (chief complaint, meds, allergies, review of systems)
  • Multidisciplinary facilities (coupling primary and specialty care closer to EDs)
  • Personnel Optimization
    • Increased specialization of different roles of health care providers
    • More systematic assignment of personnel to meet flow demands
  • Improved safety checks prior to discharge to reduce bounce-backs

case23_fig1CULTURE

Finally, the residents brainstormed on what other changes in the culture of both Medicine and being a Patient. Almost universally the group agreed that patient accountability (the flip side of the medical coin) was the number one concern. Their desire was for patients to feel more ownership and responsibility in their own care.  This seemed to be in response to the increased expectations placed on physicians in improving the value of care.

Other areas they sought improvement included:

  • Better integration between community/schools and the health care system
  • Palliative Care  teams available in the ED
  • Improved communication between Private physicians and the ED (both directions)
  • “Super Gyms” – integration between wellness facilities and hospitals
    • to improve life-style modifications.
  • Informative health videos in ER waiting rooms
  • Outpatient pain management referred directly from ED

This exercise was hugely entertaining and enjoyable for all who participated. If you would like to share your views please feel free to add a comment!

David