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Average ER Waiting Time? Planning for the Future, the Long View

August 9, 2008
by Joe Bormel
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Topic: Average ER Waiting Time? Planning for the Future, the Long View

In this week’s WSJ, there was an article on page D4 “Average ER Waiting Time Jumps to Nearly an Hour,” which summarized the CDC’s National Hospital Ambulatory Medical Care Survey: 2006 Emergency Department Summary, NHSR007, also published this week.

Here’s a few highlights:

· Source: 2006 CDC NHAMCS data, 119 Million visits, 40.5 visits/100 persons

· Comparison: from 10 years ago

· Finding: Average times: 38 min (1997), 47 min (2004), 56 min (2006) (mean waiting time to see a physician)

· In the 11th paragraph, the lead author explains that ‘Averages’ are skewed by outliers, and the correct measure to use is ‘Median’.

· Median time to see a clinician: 31 minutes

· Increasing frequency of ED visits (up 32%) and decreased number of EDs (4,900->~4,600)

· This 40 page CDC doc (NHSR007) is chock full of interesting and potentially useful benchmark data, including patient flow indicators, broader access issues, socioeconomics, and detailed utilization data.

I wanted to open the deeper HCIT issues for discussion.

What does this CDC data really mean about the healthcare system we’re trying to improve? In his book, The Art of the Long View – Planning for the Future in an Uncertain World, Peter Schwartz introduced many of us to the ‘scenaric approach.’ Probably best popularized in our HCIT industry segment by Gartner, the approach asks “what scenarios about the future might play out,” and then focus on “what are the early indicators to sort out which future is coming to pass.” This ER Waiting Time article may contain a few important early indicators.

As a brief aside, Schwartz spends several chapters on the value and mechanics of ‘Strategic Conversations. The book, first published in 1991, presaged the role and necessity of blogs, to help managers and leaders clarify thinking, understanding and correctly anticipating the external environment. In 2007, Nobel and Oscar recipient Al Gore concluded that such multi-way, strategic conversations are critical to reason and democracy functioning (or failing to). Wow, conversations may be a lot more important than most people realize.

Questions raised for conversation:

1. What are the ER Wait Times really telling us?: The ER Wait Times are supportive of the scenario of healthcare in the US becoming more fully three-tiered. From the HCIT perspective, this is best elaborated by FCG and Erica Drazen’s four truths, ending with Truth #4 here: With a single payer system doubtful anytime in the near future and reimbursement continuing to decline, the healthcare system will settle into three tiers of patient. (2007).

Economics will distribute resources, such as those driving the ER Wait Times, such as number of EDs and their characteristics, differentially across the patient tiers.

Can and will “Business Process Automation”(aka our healthcare information technologies) support these three tiers with different wait times? Is there really only one standard and one tier of service that makes any sense in terms of cost, quality and access for truly emergent care? What is the impact on tiers or lack thereof from HCIT today? Will wait times need to become longer, before better systems thinking takes hold? A few years back, demand management was growing, including calling a nurse for guidance, before meeting another nurse, the triage nurse at the ER. Is there a much stronger case for unified communications with the patient, to ameliorate the ER waiting time issue?

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Dr Peters and Jack,
Thanks for your insights. Three days after our dialogue came this:

In "Can Technology Better Manage Healthcare?"
Posted on: 8.22.2008 11:51:31 AM Posted by Joe Marion
found here:
http://healthcare-informatics.com/ME2/dirmod.asp?sid349DF6BB879446A1886B...

Joe Marion eloquently made the same point the behavior of our healthcare system is the important end-point. Optimizing crude and odd univariate statistics (e.g. time-to-be-seen-by-X) is like improving gas mileage while driving in the wrong direction.

I agree with Dr. Peters. It seems that the combination of triage and technology is really a no-brainer. However, we seem to be making little headway in the area of true interoperability for Healthcare IT. Too many of the vendors claim interoperable applications/systems, but the reality of the situation is that this interoperability exists only between the product offerings of the individual vendors. I find this to be unacceptable. What do you think, Dr. Bormel?

In "Don't Believe the Emergency-Room Laments" by Gavin Magor , here:

http://www.thestreet.com/print/story/10432526.html

Magor points out that there's an assumption of a linear trend over 10 years that's wrong and very misleading. He, too, calls into question the interpretation of the data, further inviting conversation.

As a twenty year practitioner of Emergency Medicine, a ten year history of involvement in Healthcare IT and Administration I am as passionate about data and access to information as anyone.

Attempting to compare data from ED visits ten years ago to the ED of today is bordering on ludicrous.

Even comparing data today is of limited use given the enormous diversity of categories of ED's.

With the continued rise in the uninsured population and limited access to entry into the healthcare system for all patients, insured and uninsured, overcrowding will persist as an ongoing issue.

Instead of focusing on time to seeing a physician, improvements should focus upon entry into the correct clinical pathway for each particular patient, i.e, triage and technology deciding alternate levels and areas for care at healthcare facilities.

Expanding access to care for all patients outside of the hospital may be the only true path to alleviating ED overcrowding.

Having access to patients health information via technology is the first step in opening access and limiting overutilization of resources.

Even though this technology is available and functional, far too few are embracing it.

The open access clinic concept has been in existence for years and acceptance by providers, patients and even payors has been slow to adopt the idea.

I am concerned that we are paying too much attention to mathematical terms: average, mean and median rather than to appropriate patient care.

If the healthcare "team" is designed correctly and functioning, the time to being seen by the physician is not significant.

It should be the time to receiving the correct assessment and start of the care process by the team.

"Inappropriate ER use across the board"

About a week after I posed this, a nice blog (and nine commenters) appeared here:

http://www.thehealthcareblog.com/the_health_care_blog/2008/08/talking-ab...

It got me thinking about HCIT again. A significant number of people go to the ER because of COORDINATION OF CARE problems.

As noted, although Minute Clinics are "a no-brainer", doesn't it make more sense for care-delivery organizations to offer 24-7 care coordination?

Who could/would/should pay for my local general hospital to offer a Skype "Video ER Visit" to discuss and potentially schedule follow up for my non-urgent but important symptom?

What would be the revenue impact for my local general hospital to do this?

Or should I be thinking concierge?

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Joe Bormel

Healthcare IT Consutant

Joe Bormel

@jbormel

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