Beyond Regionalization:
Experts Grapple With Research Agenda in Response to IOM Report
Article Outline
Phoenix—If emergency medicine is to respond to the Institute of Medicine's (IOM's) 2006 call for a “coordinated, regionalized and accountable”1 emergency care system—emphasis on the “regional”—then it will have to tackle significant problems of culture, competition, and distrust that have gone unsolved for decades. At the moment, no one seems sure how to do that. But judging by the frank discussions held in June at the Society for Academic Emergency Medicine's (SAEM's) 11th annual Consensus Conference, “Beyond Regionalization: Integrated Networks of Emergency Care,”2 the specialty is beginning to feel confident at least of the right questions to ask.
In an intense all-day gathering held outside Phoenix just before SAEM's annual meeting, academic physicians and invited guests from other specialties, federal agencies, and the private sector candidly confronted regionalization's core problem.
“People think it means: We will put you out of business,” said Brendan G. Carr, MD, MS, cochair of the consensus conference and an assistant professor of emergency medicine and epidemiology at the University of Pennsylvania School of Medicine. “Especially to smaller, suburban or rural hospitals, ‘regionalization’ is a 4-letter word.”
Yet regionalization—or integration, in the conference's preferred wording—is a challenge that emergency care must confront, said cochair Ricardo Martinez, MD, executive vice president of medical affairs and president of Division East at the Schumacher Group outside Atlanta, and assistant professor of emergency medicine at Emory University School of Medicine. The system's focus on “getting the right patient to the right place at the right time” has led, he said, to an overreliance on transfer that not only threatens to starve small hospitals of income but also misuses the system's resources overall.
A Good Metric is Hard to Find
Although good metrics are hard to come by, “at (DHHS, the Department of Health and Human Services), we looked at the percentage of patients who were transferred from one hospital to another and then ultimately discharged from the [emergency department {ED}], and came up with 72%,” Dr. Martinez said. “I am not yet sure I trust that number. But even if it is one-third of that, even if it is one-half of that, it is an amazingly inefficient system. We are transferring patients up for nonintervention.”
The consensus conference, which was cosponsored by the American College of Emergency Physicians, publishers of Annals of Emergency Medicine, and the Emergency Department Practice Management Association, was intended to define the key research questions that will move system integration forward. (The results will be published in an open-access December edition of Academic Emergency Medicine.) To that end, the organizers invited not only emergency physicians from a range of markets and systems but also federal officials and representatives from specialties that have developed their own models of integration.
“Lots of people have good answers for what regionalization is; what we need are better questions,” said Michael T. Handrigan, MD, director of the Emergency Care Coordination Center within DHHS (Department of Health and Human Services), which was founded in response to the IOM report. “Is it a structure or is it a process? From my perspective, it is more about the process of bringing partners together
…to meet needs and requirements locally.”
Early in the conference, participants heard from physicians in specialties that treat time-critical conditions such as ST-segment elevation myocardial infarction heart attack, trauma, and stroke, looking for lessons that could be extracted from their arrangements. Arthur Pancioli, MD, professor and executive vice-chairman of the department of emergency medicine at the University of Cincinnati College of Medicine, offered stroke response as a model for a decentralized system that permits resources to flow in 2 directions.
“Stroke doesn't require every patient to come to the center,” he said, offering the example of the Greater Cincinnati/Northern Kentucky Stroke Team, which covers 16 hospitals. “Some disease processes require technological intervention, but some require personnel intervention.” Buildings and equipment may be fixed resources, he said, but specialists' knowledge—the system's “cognitive resources”—is portable and can be shared with smaller hospitals in person or through telemedicine, he said.
Toxicology, represented by the national network of poison control centers, offers a similar model of distributing “cognitive consultations” to patients whom specialists never see, said Lewis S. Nelson, MD, associate professor of emergency medicine at New York University School of Medicine and associate medical director of the New York City Poison Control Center. But, he added, it also offers an example of the peril of distributed networks: “No poison control center has adequate and stable funding.”
The difficulty of paying for regionalized/integrated networks was raised several times during the day, including during a second experts' panel that addressed specific administrative challenges from health information technology to credentialing. “I don't think the payment system, as it is set up now, will support regionalization,” said Greg Hufstetler, CPA, MBA, of Reimbursement Technologies, Inc., a subsidiary of the giant billing/coding company EmCare Inc.
Regionalization as currently practiced has already revealed financial pitfalls, said Brent Asplin, MD, MPH, chair of the Department of Emergency Medicine at the Mayo Clinic. “If we don't address the financial incentives and disincentives in a forthright way, we won't make progress,” Dr. Asplin said. “The historical approach has been ‘send all your bad stuff to us,' but that doesn't work in competitive markets. Smaller hospitals give up patients, while referral centers worry about getting the wrong kind of patients, from a financial perspective.”
Dr. Carr, the cochair, concurred: “We can't just take the high road and talk about ‘quality.' We need to think about how to deliver quality that doesn't have the terrible unintended consequence of putting small hospitals out of business.”
Beyond payment, establishing truly integrated networks poses other administrative problems, experts said during the conference, ranging from electronic health records that are not interoperable between centers (or sometimes within single systems) to patchy expertise in out-of-hospital care. Alice Jacobs, MD, professor of medicine at Boston University School of Medicine and director of interventional cardiology and the cardiac catheterization laboratory at Boston University Medical Center, pointed to results of a nationwide survey of emergency medical services (EMS) organizations that not all ambulances transmit ECG tracings to medical centers, and not all paramedics are trained to administer ECGs.
Licensure and credentialing of personnel across newly created networks will pose formidable challenges, said Robert Wise, MD, vice president of the division of standards and survey methods at The Joint Commission. Medical centers that use telemedicine to share their specialists' knowledge across a state, or even the country—as well as centers that use specialists whose expertise is being delivered remotely—will have to decide how to certify experience and expertise at the other end of the link.
“Accountability to the patient will be one of the significant issues as we see a patient move through a network and multiple people touch that patient,” Dr. Wise said, likening the potential complexities to the finger-pointing that arises in accounting for health care–associated infections. Liability and reimbursement are especially difficult considerations in pediatric emergency care, added Marianne Gausche-Hill, MD, director of EMS and of the EMS and pediatric emergency medicine fellowships at Harbor-UCLA Medical Center.
The Right Questions
To begin tackling the many challenges in a research-focused way, the conference divided into 8 small working groups, each tasked with coming up with prioritized research questions:
Each group's main talking points had been worked out in advance among participants, and discussions quickly launched into the sticking points inherent in each subject. In the patient-centered networks breakout, for instance, participants focused quickly on the difficulties that transport to a tertiary care center can impose on patients' families, who may unexpectedly face long drives, expensive hotel stays, and difficult child care issues if they want to be with their loved one.
“Do we actually ask patients what they want?” asked one participant in the session, who identified himself as a physician in private practice. “From our experience developing primary care clinics in the community, they are wanting quick access to care for the easy stuff. We focus, because it's of interest to us, on the sexy stuff. But ‘how do I deal with my kid who needs to come home from school when I am not there’ is the sort of worry that patients are having.”
Similarly, participants in the workforce session shared concerns over the difficulty in getting residency-trained, board-certified emergency physicians (EMRT/BCs) to accept jobs in areas with smaller hospitals that lose their most interesting patients to referral centers. Already, said one participant, 13% of all ED visits are handled primarily by nurse practitioners or physician assistants, and 5% of visits never involve an emergency physician at all.
“Will it be attractive for residents to work there?” he asked. “And if not, how do we maintain the skills and knowledge of the [other] providers who are already out there?”
At the end of the conference, participants emerged from the small-group sessions with agreed-on lists of major research questions for each topic. As a final step, the organizers asked each group to post their list of questions on the conference room's walls and then invited all the participants to vote by colored sticker for what they considered the highest-priority issues.
For some topics, urgent issues emerged quickly. Under “Patient-centered networks,” for instance, almost all the votes went to the questions, “How do we really measure what is important to patients? How do we prioritize (those metrics) in addition to medical outcomes?” Under “Pre-hospital care,” the majority of votes went to the research question, “What patients need a specialty center?,” and under “Matching networks to patient needs,” the majority voted for “What incentives can help us transform from a competitive environment to a cooperative community that augments system capacity?”
Tackling Uncertainty
Other topics, though, demonstrated how much uncertainty regionalization or integration can evoke. Under “Defining and measuring successful networks,” voting was evenly divided between “What are the fundamental metrics that measure the network across time- and non-time-sensitive conditions?” and “How do we promote linkage of data systems across the course of disease?” Similarly, under “Interhospital communication and transport,” votes were evenly divided between “How can modern technologies including telemedicine, personal digital assistant data transmission, global positioning satellite and real-time census-tracking systems be employed to facilitate optimal patient distribution, leveling and outcomes?” and “Who assures that the communication and transport network is working in the best interests of the patient?”
“Electronic collaboration” experienced a 3-way split, with votes divided among the research questions, “How do we effectively capture pre-hospital data through discharge home?,” “Do protocol and guideline adherence improve outcomes?,” and “Is there a return on investment to adding visual to telephones, and what are the effects on outcomes?”
The most contentious questions, though, were clearly the workforce ones: The sheet holding the proposals from the “Emergency and on-call workforce” session was so studded with stickers it was difficult to read. Participants voted almost equally for all of that group's research questions: “What is the quality/cost/other benefit of EMRT/BCs versus other emergency providers?”; “What incentives are needed to recruit EMRT/BCs to non-urban areas?”; “What are good emergency medicine quality markers, and how do they affect workforce?”; “Where are the gaps/needs for the non-emergency physician emergency care workforce?”
The final question of the list was clearly the hardest for participants to answer: “What is the minimum expectation of the US public for emergency care?”
References
- . Hospital-based emergency care: at the breaking point. http://www.iom.edu/Reports/2006/Hospital-Based-Emergency-Care-At-the-Breaking-Point.aspxAccessed May 22, 2010
- . 2010 Academic Emergency Medicine consensus conference, June 2, 2010, Phoenix, AZ. http://www.saem.org/saemdnn/Meetings/AnnualMeeting2010/AEMConsensusConference2010June2/tabid/1349/Default.aspxAccessed May 20, 2010
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The authors have stated that no such relationships exist. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement.
Section editor: Truman J. Milling, Jr, MD
PII: S0196-0644(10)00591-3
doi:10.1016/j.annemergmed.2010.06.007
