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Utilization Crisis in the ED?

August 15, 2011
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It’s time for patient care leaders to look at ED over-utilization—before the feds catch up with it first

A recent survey by the Wall, N.J.-based Healthcare Intelligence Network elicited the following results from healthcare executives:

> About 94 percent of respondents reported that avoidable emergency department (ED) visits present a problem for them.
> According to 34.1 percent of survey respondents, the majority of preventable ED visits were for conditions that could have been treated more efficiently in another healthcare setting.
> About 29.3 percent said high utilizers were the top contributors to avoidable ED use.
> About 60 percent said funding is the greatest barrier to launching a program to reduce ED use.

Now, this is one of those fascinating situations that pose intricate, interlocking healthcare conundrums (just like the 1,001 other situations involving conundrum-like circumstances in healthcare). On the one hand, there is no question that healthcare reimbursement—first through healthcare reform and the Medicare program—is over the next 10 years going to become more and more challenging when it comes to the “high-flyer” patients who come back again and again for care under the Medicare program. Those folks are definitely a collective target on the part of policymakers when it comes to avoidable utilization—both inpatient and ED; and of course, they’re already being directly targeted in the inpatient sphere, with regard to “unnecessary readmissions” in the Medicare program, under federal healthcare reform. It’s no stretch to contemplate that a direct federal move against on ED overutilization itself is not long off at all.

On the other hand, the various information systems that need to be leveraged thoughtfully in order to determine who the over-utilizers are, take care of them in a more optimal manner, and make the nation’s EDs far more efficient, are still in their relative infancy in terms of being used. For one thing, most hospitals are still struggling with the issue of whether to shift from having an ED EHR separate from their organizations’ core EHRs (and that whole sub-conundrum is causing tremendous angst and confusion when it comes to meaningful use-related issues). For another, the implementation and leveraging of business intelligence systems, as applied to ED clinical operations—in other words, the plunge into clinical intelligence—is truly embryonic—or even still non-existent—in most hospital organizations today.

This is one of those instances in which, in order for hospital and health system leaders to be successful along a host of dimensions, they will have to be moving the ball forward on a number of fronts simultaneously—developing ED EHR and clinical intelligence capabilities (that’s two different fronts right there), while at the same time going into overdrive in terms of case management-based data analysis and population health efforts (another two), while also looking at the patient-centered medical home model and the accountable care organization (ACO) model at the same time (yet another two).

Don’t get me wrong: I’m not saying that healthcare leaders should wildly and haphazardly lunge forward in all these areas at once; such an approach would inevitably spell disaster. But what I am saying is that the only way to get a handle on a truly significant problem—ED over-utilization by a relatively small group of high-intensity “high-flyer” patients—will be to move forward strategically under a broad banner of performance optimization, with all the key stakeholder groups in the ED and the inpatient hospital organizations represented, and a strong sense of vision and mission. And fully leveraging the most relevant and sophisticated clinical information systems and data analytics systems will be essential to success in this area. What’s more, the robust participation of CIOs, CMIOs, and other informatics leaders in any such efforts will be vital to their success.

The flip side of all this is obvious: sometime in the not-too-distant future, as the hammer really gets lowered on ED overutilization, both by the federal government, through Medicare, and in the private health insurer sphere as well—those healthcare leaders who haven’t moved their organizations forward in this area will find themselves in panic mode, and when it comes to the high levels of reimbursement involved in this critical area of patient care, that is simply not a good place. And don’t say we didn’t warn you.